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HomeMy WebLinkAbout1046 MAIN STREET (OST.) - Health 1046 Main Street (Ost.) Osterville P A — `118 01500X ° ° && F a oh Commonwealth of Massachusetts � -ao-A Title 5 Official Inspection Form � Subsurface Sewage Disposal System Form - Not for Voluntary Assessments f� 1046 Main Street Property Address Villa e West Condo's Owner Owner's Name information is �/ MA 02655 10/21/2018 required for every OSterVllle rxr page. City/Town State Zip Code Date of Inspection -� r�•i Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When A. General Information cS/ .#f- /3485 filling out forms on the computer, use only the tab 1 Inspector: key to move your cursor-do not James Ford use the return Name of Inspector key. Ford Septic Services, LLC rb Company Name P.O. Box 49 Company Address Osterville MA 02655 Cistervin State Zip Code 508-862-9400 S 12482 e Number Telephone Number License B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 16.000).The system: ® Passes ❑ Conditionally Passes ❑ Fails SInspe Needs Further v uation by the Local Approving Authority 10/24/2018 o Signature Date The s m inspecto shall Is a copy of this inspection report to the Approving Authority (Board of Health or DEP)within 30 days of completing this inspection. If the system has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate hould be sent to the system owner and copies sent to the regional office of the DEP. The original s buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. Title 5 Official inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 15ins.doc•rev.5116 I commonwealth of Massachusetts tion FOm Title 5 Official InspecAssessments Subsurface Sewage Disposal System Form -Not for Voluntary 1046 Main Street Property Address Villa e West Condo's Owner owner's Name MA 02655 -- 10/21/2018 information is Osterville State Zip Code Date of Inspection required for every CitylTown page. B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D q) System Passes: riteria ® 04 I have not found any information which indicateexis Any fail�e crtenaf the unot re cevaluated are in 310 CMR 15.303 or in 310 CMR indicated below. Comments: B) System Conditionally Passes: pass" section need to be ❑ One or more system components as describe et on in hof the reiplaceiment or repair, as approved by replaced or repaired. The system, upon comp the Board of Health, will pass. Check the box for"yes", "no" or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old* or the septic tank(whether metal Of not) is structurally unsound. exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tanK Is repiaceu wan a complying oopt��ta,h ao aPP�o Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): tsfns.doc•rev-6/16 - Title 5 official Inspection Form:Subsurface Sewage Disposal system•Page 2 of 17 r Commonwealth of Massachusetts T it 5 official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form - 1046 Main Street Property Address Village West Condo's Owner Owner's Name MA 026_ 55 _ 10/21/2018 information is OSteNille State Zip Code Date of Inspection required for every -§_y own page. B. Certification (cont.) approval if ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health pumps/alarms are repaired. B) System Conditionally Passes (cont.): ion of sewage backup or break out or high static water level in the the ibu ution botio box due to broken or obstructed pipe(s)❑ at or due to a broken, settled or uneven m will to broken pass inspection if(with approval of Board of Health): ❑ Y ❑ N ❑ ND (Explain below): ❑ broken pipe(s) are replaced ❑ y El ❑ ND (Explain below): ❑ obstruction is removed distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y N ❑ min (GYrlain below): ❑ Y N ND (Expirain below): obstruction is removed ❑ ❑ C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 t5ins.doc•rev.6116 Commonwealth of Massachusetts Form _ Title 5 official Inspection posal System Form -Not for Voluntary Assessments Subsurface sewage Dis 1046 Main Street Property Address Villa e West Condo's 10121/2018 Owner owner's Name MA 02655 _ information is Osterville State Zip Code Date of Inspection required for every city(Town page. B. Certification (cont.) of Health (and Public Water Supplier, if any) 2. System will fail unless the Board oning in a manner that protects the public health, determines that the system is functi safety and environment: and the SAS is within ❑ The system has a septic an andtsoil butary to absorption surfaceewateAsuppiy. 100 feet of a surface water supply o The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. eptic tank and SAS and the SAS is within 50 feet of a private water ❑ The system has a s supply well. ic tank and SAS and the SAS is less than 100 feet but 50 feet or ❑ The system has a sept more from a private water supply v Method used to determine distance: ** if the well water analysis, performed at a DEP certified laboratory, for fecal This system passes presence of ammonia nitrogen and nitrate nitrogen is equal coliform bacteria indicates absent and the p 99 A copy of the analysis must to or less than 5 ppm, provided that no other failure criteria are tri eyed. be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ' Static liquid level in the distribution box above outlet invert due to an overloaded ❑ ® or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than 'h day flow t5ins.doc•rev.6I116 Title 5 Official Inspection Form:Subsurface Sewage Disposal system•Page 4 of 17 I Commonwealth of Massachusetts Title 5 official • Inspection Form �a I !" Subsurface Sewage Disposal System Form Not for Voluntary Assessments 1046 Main Street Property Address Villa e West Condo's 10/21/2018 Owner Owner's Name MA 02655 information is osterville State Zip Code Date of Inspection required for every cityrrown page. B. Certification (cost.) Yes No Required pumping more than 4 times in the last year NOT due to clogged or 0 ® obstructed pipe(s). Number of times pumped: -- E] ® Any portion of the SAS, cesspool or privy is below high ground water elevation. An onion of cesspool or privy is within 100 feet of a surface water supply or Yp ❑ ® tributary to a surface water supply. ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® portion of a cesspool or privy is less than 100 feet but greater than 5s feet This [] ® Any I well with no acceptable waterquality from a private water supply system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or ley of the analysis provided that no other failure criteria are triggered. A copy and chain of custody must be attached to this forth.] r I m With n design flow of 200090- ® 10,000gpd. ® The system fails. I have aetermined that one or more of the above failure Criteria exist as described in 310 BCMR therefore deterhe sstem mine what wi fails. he system owner should contact theoard of Health to necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no" to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (interim Wellhead Protection Area—IWPA) or a mapped Zone II of a public water supply well If you have answered"yes" to any question in Section E the system is considered a significant threat, ' or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. Title 5 Official Inspection Form:Subsurface Sewage Disposal system•Page 5 of 17 t5ins.doc•rev.6116 c Commonwealth of Massachusetts Title 5 Official Inspection Form sments � Subsurface Sewage Disposal System Form Not for Voluntary 1046 Main Street Property Address Village West Condo's Owner Owner's Name 10/21/2018 information is Cisterville MA 02655 required for every State Zip Code Date of Inspection page. CitylTown C. Checklist Check if the following have been done. You must indicate"Yes" or"no" as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? Have large volumes of water been introduced to the system recently or as part of El ® this inspection? Were as built plans of the system o El ® btained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank affles or tees, material of construction, inspected for the condition of the b dimensions, depth of liquid, depth of sludge and depth of scum? Was the facility owner(and occupynts if f different subsurface sewage disposal systems? 0 ® information on the proper maintenance o The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ❑ ® Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: n/a n/a _ Number of bedrooms (design): Number of bedrooms (actual): n/a DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 t5ins.doc•rev.6116 Commonwealth of Massachusetts - Title 5 official Inspection Form I. o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1046 Main Street `J Property Address Villa e West Condo's Owner owner's Name MA 02655 10/21/2018 information is OSterville State Zip Code Date of Inspection required for every City/Town page. D. System Information Description: 0 -- Number of current residents: ❑ Yes ® No Does residence have a garbage grinder? Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) ❑ Yes ® No Laundry system inspected? ❑ Yes ® No Seasonal use? Water meter readings, if available (last 2 years usage (gpd)): Detail: unavailable ❑ Yes ® No Sump pump? Last date of occupancy: Date Commercial/Industrial Flow Conditions' Office Building Type of Establishment: unknown Design flow(based on 310 CMR 15.203): Gallons per day(es 13 rental offices Basis of design flow (seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ® No Industrial waste holding tank present? ❑ Yes No � Non-sanitary waste discharged to the Title 5 system? El Yes ® No unavailable Water meter readings, if available: Title 5 of riai inspection Form:Subsurface sewage Disposal System•Page 7 of» t5ins.doc•rev.6116 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1046 Main Street Property Address - Villa e West Condo's Owner Owner's Name information is Osterville MA 02655 10/21/2018 required for every State Zip Code Date of Inspection page. Cityrrown D. System Information (cost.) currently Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: pumped yearly Source of information: Was system pumped as part of the inspection? ® Yes ❑ No If yes, volume pumped: gallons How was quantity pumped determined? yearly maintenance Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a Copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. I ❑ Other(describe): Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page a of 17 t5ins.doc•rev.6116 Commonwealth of Massachusetts :-. Title 5 Official Inspection Form - Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1046 Main Street Property Address Village West Condo's Owner Owner's Name information is Osterville MA 02655 10/21/2018 required for every State Zip Code Date of Inspection page. CitylTown D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: installed date unknown Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: feet Material of construction: ❑ cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments(on condition of joints, venting, evidence of leakage, etc.): Septic Tank(locate on site plan): Depth below grade: feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years � ❑ ❑ Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) Yes No 2000 gal. H-20 Dimensions: 3 Sludge depth: Title 5 Official inspection Form:Subsurface Sewage Disposal System-Page 9 of 17 t5ins.doc-rev.6116 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments .� 1046 Main Street v Property Address Village West Condo's Owner Owner's Name information is Osterville MA 02655 10/21/2018 required for every State Zip Code Date of Inspection page. City(Town D. System Information (cont.) Septic Tank (cont.) Distance from top of sludge to bottom of outlet tee or baffle 32 1 Scum thickness 5 Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle 12 measure How were dimensions determined? Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): The Tees were present. The liquid level was even with the outlet invert. There was no sign of leakage. Steel covers were to grade Grease Trap (locate on site plan): N/a Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle ' Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 t5ins.doc•rev.6116 c Commonwealth of Massachusetts �v Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1046 Main Street Property Address Villa e West Condo's Owner Owner's Name information is required for every Osterville MA 02655 10/21/2018 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): N/a Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of fast pumping: Date Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17 t5ins.doc-rev.6116 Commonwealth of Massachusetts Title 5 Official .Inspection Form l Subsurface Sewage Disposal System Form Not for Voluntary Assessments 1046 Main Street Property Address Villa e West Condo's Owner Owner's Name information is Osteryille MA 02655 10/21/2018 required for every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert even Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): D-box was normal. Steel cover was to grade. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): N/a * If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: I Title 5 Official Inspection Form:Subsurface Sewage Disposal system•Page 12 of 17 t5ins.doc•rev.6116 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1046 Main Street �v Property Address Village West Condo's Owner Owner's Name information is required for every Osteryille MA 02655 10/21/2018 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: 2- 1000 gal. ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): The pits had 3' of water on the bottom No sign of failure Steel covers were to grade. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): N/a Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool E Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 c� Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1046 Main Street Property Address Village West Condo's Owner Owner's Name information is Osterville MA 02655 10/21/2018 required for every State Zip Code Date of Inspection page. CitylTown D. System Information (cont.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)-. Privy (locate on site plan): N/a Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 15ins.doc•rev.6116 I Commonwealth of Massachusetts Title 5 Official Inspection Form � Subsurface Sewage Disposal System Form =Not for Voluntary Assessments 1046 Main Street Property Address Village West Condo's Owner Owner's Name information is Osterville MA 02655 10/21/2018 required for every State Zip Code Date of Inspection page. City/Town D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view ofor benchmarks. Locate all wells within 100 feet includinge sewage disosal system, Locateies o at least two permanent reference landmarks where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately C o \)Cr�S TO G rA�-�- Title 5 Official Inspection Form:Subsurface Sewage Disposal system•Page 15 of 17 15ins.doc•rev.6116 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1046 Main Street r'~ Property Address Village West Condo's ,Owner Owner's Name information is Osterville MA 02655 10/21/2018 required for every State Zip Code Date of Inspection page. City/Town D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells 20' groundwater Estimated depth to high ground water: feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: pate ❑ Observed site (abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health -explain: To o and water contours ma ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database -explain: You must describe how you established the high ground water elevation: see above Before filing this Inspection Report, please see Report Completeness Checklist on next page. Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 t5ins.doc•rev.6116 Commonwealth of Massachusetts Title 5 Official Inspection Form } Subsurface Sewage Disposal System Form Not for Voluntary Assessments v � 1046 Main Street Property Address Village West Condo's Owner Owner's Name information is Osterville page Ci MA 02655 10/21/2018 required for every tylTown State Zip Code Date of Inspection E. Report Completeness Checklist ❑ Inspection Summary: A, B, C, D, or E checked ❑ Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ❑ System Information—Estimated depth to high groundwater ❑ Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 l5ins.00c•rev.6/15 Commonwealth of Massachusetts 07,5" ODA Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments w 1046 Main Street O Property Address C 1046 Main Street Condo's -Scott Peacock manager Owner Owner's Name information is required for every Osterville ✓ MA 02655 10/12/2016 __ page. Cityrrown State Zip Code Date of Inspection N 0. Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When A. General Information filling out forms (�/ t� 1917 on the computer, V r use only the tab 1. Inspector: key to move your cursor-do not James Ford key the return Name of Inspector Y Ford Septic Services, LLC LbCompany Name P.O. Box 49 Company Address Osterville MA 02655 Cityrrown State Zip Code 508-862-9400 S12482 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000). The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority 10/26/16 Insp c is Signature Date The tem inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 s Commonwealth of Massachusetts = Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments •'•y 1046 Main Street Property Address 1046 Main Street Condo's-Scott Peacock manager Owner information is Owner's Name required for every Osterville MA 02655 10/12/2016 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® 1 have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: ❑ One or more system components as described in the "Conditional Pass" section need to be replaced or repaired.The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no" or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old"or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration orexfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17 r Commonwealth of Massachusetts H Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments a 1046 Main Street Property Address 1046 Main Street Condo's -Scott Peacock manager Owner Owner's Name information is required for every Osterville MA 02655 10/12/2016 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the.environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1046 Main Street Property Address - 1046 Main Street Condo's -Scott Peacock manager Owner Owner's Name information is required for every Osterville MA 02655 10/12/2016 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No El ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ E Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/2 day flow l5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal system;Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1046 Main Street Property Address 1046 Main Street Condo's-Scott Peacock manager Owner O wner's Name information is required for every Osterville MA 02655 10/12/2016 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails.I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area— IWPA)or a mapped Zone II of a public water supply well If you have answered "yes"to any question in Section.E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. l5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 i Commonwealth of Massachusetts Amm. Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 1046 Main Street Property Address 1046 Main Street Condo's -Scott Peacock manager Owner Owner's Name information is required for every Osterville MA 02655 10/12/2016 page. Cityrrown State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes"or"no"as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ❑ ® Were as built plans of the system obtained and examined?(If they were not available note as N/A) ❑ ® Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the Condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ❑ ® Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): Number of bedrooms (actual): DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 15ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal system•Page 6 of 17 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1046 Main Street Property Address 1046 Main Street Condo's -Scott Peacock manager Owner Owner's Name information is required for every Osterville MA 02655 10/12/2016 page. City/Town State Zip Code Date of Inspection D. System Information Description: Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system?(Include laundry system inspection information in this report.) ❑ Yes ® No Laundry system inspected? ❑ Yes ® No Seasonal use? El Yes ® No Water meter readings, if available (last 2 years usage (gpd)): Detail: unavailable Sump pump? ❑ Yes ® No Last date of occupancy: currently Date Commercial/Industrial Flow Conditions: Type of Establishment: office building- 13 units Design flow(based on 310 CMR 15.203): unknown Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ® No Industrial waste holding tank present? ❑ Yes ® No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ® No Water meter readings, if available: unknown t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1046 Main Street Property Address 1046 Main Street Condo's -Scott Peacock manager Owner Owner's Name information is required for every Osterville MA 02655 10/12/2016 page. CitylTown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: current) Date Other(describe below): General Information Pumping Records: Source of information: pumped yearly Was system pumped as part of the inspection? ® Yes ❑ No If yes, volume pumped: 1500 gallons How was quantity pumped determined? Reason for pumping: maintenance Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments w 1046 Main Street Property Address 1046 Main Street Condo's - Scott Peacock manager Owner Owner's Name information is required for every Osterville MA 02655 10/12/2016 page. City/Town State ZipCode Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known)and source of information: system installed -date unknown Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Septic Tank (locate on site plan): Depth below grade: 15" feet Material of construction: ® concrete ❑ metal ❑fiberglass ❑ polyeth lene y El other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1500 gal. H-20 Sludge depth: 2 t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1046 Main Street Property Address 1046 Main S tr e et Con dos _ Scott Peacock manager Owner's Nameinformation is required for every Osterville MA 02655 10/12/2016 page. City/Town State Zi Code P Date of Inspection D. System Information Y (cont. Septic Tank (cont.) Distance from top of sludge to bottom of outlet tee or baffle 29 Scum thickness 2 Distance from top of Scum to top of outlet tee or baffle 6 Distance from bottom of scum to bottom of outlet tee or baffle 10 How were dimensions determined? measure Comments (on pumping recommendations, inlet and outlet tee or baffle condition,.structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): There were cement tee's present.There was no sign of leakage. The tank was pumped for maintenance. The system is in the parking lot and steel covers are to grade Grease Trap(locate on site plan): Depth below grade: n/a feet Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene Y ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date 15ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for VoluntaryAssessments ssments 1046 Main Street Property Address 1046 Main Street Condo's-Scott Peacock manager Owner Owner's Name information is required for every Osterville MA 02655 10/12/2016 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene El other(explain): N/a Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): "Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No l5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1046 Main Street Property Address 1046 Main Street Condo's -Scott Peacock manager Owner Owner's Name information is required for every Osterville MA 02655 10/12/2016 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert even Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): The D-box was normal. no solids were present. Steel cover was to grade Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances,etc.): * If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts = Title 5 Official Inspection p coon Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments wM a °y 1046 Main Street Property Address 1046 Main Street Condo's-Scott Peacock manager Owner Owner's Name information is required for every Osterville MA 02655 10/12/2016 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: 2- 1000 gal. ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): The pits had 2' of water on the bottom. There was no sign of failure. The pits are H-20 and Steel covers were to grade. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration n/a Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal system•Page 13 of 17 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °,M a 1046 Main Street Property Address Owner 1046 Main Street Condo's -Scott Peacock mana er Owner's Name information is required for every .Osterville MA 02655 10/12/2016 page. CitylTown State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): N/a t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 i Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments w, r 1046 Main Street Property Address 1046 Main Street Condo's -Scott Peacock manager Owner Owner's Name information is required for every Osterville MA 02655 10/12/2016 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately 0 c� _I . O 01 O ro G r� l5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts _ W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1046 Main Street Property Address 1046 Main Street Condo's -Scott Peacock manager Owner Owner's Name information is required for every Osterville MA 02655 10/12/2016 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: 25'+/- feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ® Observed site (abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health -explain: Topo and water contours map. ❑ Checked with local excavators, installers - (attach documentation ❑ Accessed USGS database -explain: You must describe how you established the high ground water elevation: see above Before filing this Inspection Report, please see Report Completeness Checklist on next page. l5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System.-Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for VoluntaryAssessments sessments 1046 Main Street Property Address Owner 1046 Main Street Condo's-Scott Peacock manager information is Owner's Name required for every Osterville MA 02655 10/12/2016 page. Cityli own State Zi Code P Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems)completed ® System Information— Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file 15ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 COMMONWEALTH OF.MASSACHUSETTS t. EXECUTIVE'OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION TITLE 5 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM ., PART A CERTIFICATION Property Address: 1046 Main Street Osterville.MA 02655 Owner's Name: Villaze West Cando Association Owner's Address: Date of Inspection: February 4, 2013 Name of Inspector: (Please Print) James M.Ford Company Name: James M.'Ford Mailing Address: P.O.Box 49 Osterville:MA'02655-0049 . Telephone Number: (508)862-9400 . CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I.am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: ✓ Passes Conditionally Passes ds Further Evaluation by the Local Approving Authority ail Inspector's Signature: Date: February 7, 2013 The system inspector shall sub t a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the.system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving authority. Notes and Comments ****This report only describes conditions at the time of inspection and under the conditions of.use at that time. This inspection does not address how the system will perform in the future under the same or.different conditions of use. Title 5 Inspection Fonn 6/15/200.0 page 1 • Page 2 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 1046 Main Street Osterville,MA Owner: Village West Condo Association Date of Inspection: February 4. 2013 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D �f A. System Passes: ✓ I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: i B. System Conditionally Passes: One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. Answer yes,no or not determined(Y,N,ND)in the for the following statements. If"not determined",please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it.is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: } Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if (with approval of Board of Health): broken pipes)are replaced obstruction is removed distribution box is leveled or replaced ND explain: The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ;g broken pipes)are replaced r obstruction.is removed ND explain: 2 ' r Page 3 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 1046 Main Street Osterville.MA Owner: Village West Condo Association Date of Inspection: February 4, 2013 C. Further Evaluation is Required by the Board of Health: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health,safety or the environment. F_ { 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303 (1)(b) that the system is not functioning in a manner which will protect public health,safety and the environment: _ Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the system is functioning in a manner that protects the public health,safety and environment: The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or.tributary to a surface water supply. The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. The system has a septic tanl:and SAS and the SAS is within 50 feet of a private water supply well. The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance "This system passes if the well water analysis,performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: • u 3 i Page 4 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A .CERTIFICATION (continued) Property Address: 1046 Main Street _ Osterville.MA Owner: Village West Condo Association Date of Inspection: February 4, 2013 D. System Failure Criteria applicable to all systems: You must.indicate either"yes"or"no"to each of the following for all inspections: Yes No ✓ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ✓ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ✓ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ✓ Liquid depth in cesspool is-less than 6"below invert or available volume is less than%z day flow ✓ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped_ ✓ Any portion of the SAS,cesspool or privy is below high ground water elevation. ✓ Any portion of cesspool or privy is within 100 feet of.a surface water supply or tributary to a surface water supply. ✓ Any portion of a cesspool or privy is within a Zone 1 of a public well. ✓ Any portion of a.cesspool or privy is within 50 feet of a private water supply well. ✓ Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form.] No (Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as described in'310 CMR 15.303,therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. f E. Large System: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) Yes No the system is within 400 feet of a surface drinking water supply _ the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area-IWPA)or a mapped Zone II of a public water.supply well If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered "yes"in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 4 Page 5 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 1046 Main Street Osterville.MA ; Owner: Village West Condo Association Date of Inspection: February 4. 2013 Check if the following have been done: You must indicate"yes"or"no"as to each of the following: Yes No ✓ Pumping information was provided by the owner,occupant,or Board of Health s� ✓ Were any of the system components pumped out in the previous two weeks? ✓ Has the system received normal flows in the previous two week period? ✓ Have large volumes of water been introduced to the system recently or as part of this inspection? ✓ _ Were as built plans of the system obtained and examined?(If they were not available note as N/A) ✓ Was the facility or dwelling-inspected for signs of sewage back up? ✓ Was the site inspected for signs of break out? ✓ Were all system components,excluding the SAS,located on site? ✓ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition of the baffles or tees,material of construction;dimensions,depth of liquid,depth of sludge and depth of scum? ✓ Was the facility owner(and.occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: Yes No ✓ _ Existing information. For example,a plan at the Board of Health. ✓ _ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(3)(b)]. s d 5 'p Page 6 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 1046 Main Street Osterville,MA Owner: Villaze West Condo Association Date of Inspection: February 4, 2013 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): - Number of bedrooms(actual): - DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): - Number of current residents. Does residence have a garbage grinder(yes or no): - Is laundry on a separate sewage system(yes or no): - [if yes separate inspection required] Laundry system inspected(yes or no): - Seasonal use(yes or no): - - - Water meter readings,if available(last 2 years usage(gpd)): Sump Pump(yes or no): Last date of occupancy: COMMERCIAL/INDUSTRIAL Type of establishment: Office space Design flow(based on 310 CMR 15.203): gpd Basis of design flow(seats/persons/sq/ft etc.): 12 or 13 units a Grease trap present(yes or no): No Industrial waste holding tank present(yes or no) no Non-sanitary waste discharged to the Title 5 system(yes or no): no Water meter readings,if available: Unavailable Last date of occupancy/use: Currently occupied OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: Unknown Was system pumped as part of the inspection'(yes or no): If yes,volume pumped: gallons--,�Iow was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM ✓ Septic tank,distribution box,soil absorption system Single cesspool Overflow cesspool Privy Shared system(yes or no) (if yes,attach previous inspection records,if any) Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) Tight Tank Attach a copy of the DEP approval Other(describe): Approximate age of all components,date installed(if known)and source of information: Date of installation - Unknown Were sewage odors detected when arriving atthe site(yes or no): No 6 Page 7 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 1046 Main Street Osterville,MA Owner: Village West Condo Association Date of Inspection: February 4. 2013 BUILDING SEWER(locate on site plan) Depth below grade: Materials of construction: _cast iron _40 PVC other(explain): Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK: ✓ (locate on site plafi) Depth below grade: 12" Material of construction: ✓ concrete _metal _fiberglass _polyethylene _other(explain) If tank is metal list age: Is age confirmed by a Certificate of Compliance(yes or no): (attach a copy of certificate) Dimensions: 2000 gal. Sludge depth: 2" Distance from top of sludge to bottom of outlet tee or baffle: 30" Scum thickness: 1" Distance from top of scum to top of outlet tee;or baffle: 6" Distance from bottom of scum to bottom of outlet tee or baffle: 10" How were dimensions determined: Measuring stick Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.). The Tees were Present. The liquid level was even with the outlet invert There did not appear to be any signs of leakage Steel covers are to grade. GREASE TRAP: None (locate on site plan) Depth below grade: Material of construction: _concrete _metal _fiberglass_polyethylene _other (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee.'or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): 7 }i Page 8 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) =I Property Address: 1046 Main Street Osterville,MA' Owner: Village West Condo Association Date of Inspection: February 4, 20 3 TIGHT or HOLDING TANK: None (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of construction: _concrete _metal _fiberglass _polyethylene _other(explain): Dimensions: Capacity: gallons Design Flow: gallons/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX: ✓ (if present must be opened)(locate on site plan) 'i Depth of liquid level above outlet invert: Even Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakage into or out of box,etc.): The D-box was normal. Steel cover was to grade PUMP CHAMBER: None (locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no) Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): 'i 8 1 t Page 9 of 11 . OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 1046 Main Street Osterville,MA Owner: Village West Condo Association Date of Inspection: February 4. 2013 SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan,excavation not required) If SAS not located explain why: 't2 Type ; ✓ leaching pits,number: 2-6'x6'Pits 1000 gal. 2'stone per as built leaching chambers,number: leaching galleries,number: leaching trenches,number,length: :' ` leaching fields,number,dimensions: overflow cesspool,number: Innovative/alternative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,etc.): The pit are working. There did not appear to be any signs of failure. Steel covers are to grade. CESSPOOLS: None (cesspool must be, pumped as part of inspection)(locate on site plan) '1 Number and configuration: Depth-top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater inflow(yes or no): Comments (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): PRIVY: None (locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): 9 i u Page 10 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEV�AGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) a : Property Address: 1046 Main Street _ Osterville.MA ` Owner: Village West Condo Association Date of Inspection: February 4. 2013 SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. I , /ill Covtrt rt, SrA� O O O `! prlcmj A req P,OA 10 r f Page 11 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 1046 Main Street Osterville,MA Owner: Village West Condo Association Date of Inspection: February 4. 2013 SITE EXAM Slope Surface water Check cellar Shallow wells s� Estimated depth to ground water 20+/- feet Please indicate (check) all methods used to determine the high ground water elevation: Obtained from system design plans on record- If checked, date of design plan reviewed: Observed site(abutting property/observation hole within 150 feet of SAS) ✓ Checked with local Board of Health-explain: Topographic and water contours Wraps Checked with local excavators,installers-(attach documentation) Accessed USGS database-explain: b You must describe how you established the high ground water elevation: Using Barnstable topographic and water contours maps, the maps were showing approximately 20+/-to ground water at this site. i This report has been prepared only for=the septic system and components described herein. This septic system has been inspected and passed as of the date of inspection. This report is not a warranty or guarantee that the system will fimction properly in the fixture. There have been no warranties or guarmitees,either expressed, written or implied, relating to the septic system, the irispectibri, this report and/or any components of the septic system which have not been located and inspected. OFF,c e- TOWN OF BARNSTABLE LOCATION �©t'{�® ��4v SEWAGE# -7 5� VILLAGE —C�S��`t�\� ASSESSOR'S MAP&PARCEL i`7- 1G 4., , 5" INSTALLERS NAME&PHONE NO. SEPTIC TANK CAPACITY �� l LEACHING FACILITY:(type) Q (size) ac-,-p� ntt k U NO.OF BEDROOMS �L�C OWNER V ,l�± - C-�Vff X-r PERMIT DATE: _ 1 3 777 COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility(If any wells exist cn site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet FURNISHED BY r r - o , 'fix.(= Li �i 9 N O BARNSTABLE �� r �� � � � LOCATION ,-,"• SEWAGE VILLAGE o�1' �-� 1 `e, ASSESSOR'S MAP 6t LOT ( °" PC4t INSTALLER'S NAME & PHONE NO. Le•A► SEPTIC TANK CAPACITY 1-0® O CA--k, -ow� LEACHING FACILITY:(typec-1 I L®On cAld-p�(size) NO. OF BEDROOMS '""'-r' OR PUBLIC WATER BUILDER OR OWNER3'LVA tC.c,,C,vc.t DATE PERMIT ISSUED: t t ts�qj DATE COMPLIANCE ISSUED: / VARIANCE GRANTED: Yes No. / ` SrZ� v e f 08/TUE 10; 56 COMM FIRE DEPARTMENT Fi -X No, 5087902385 P. 001 'A' 3: .,i^ " L : o f rfi CENTERVILLE-OSTERVILLE—MARST®NS MILLS SIRE DISTRICT ` s; DEPARTMENT OF FIRE-RESCUE: & EMERGENCY SERVICES `4 :875 Falmouth Road, Rte. 28 Emergency Number: t i! Centerville, MA 02632-31 17 Bus',.ness; (508)790-2375 John M. Farrington Facsimile: (508) 790-2385 Fire Prevention/Administration Chief of Department Facsimile: (508) 957-8239 Dispatch Center FAX COMMUNICATION MESSAGE Na T,O. rat' �� r ..� �� J �® m t b r) f irsH�`i' k s, i `>< R WEARE SENDING tt�9- ;a;, , ( J _) GAGES, INCLUDING THIS COVER SHEET. PLEASE CALL (508)790-2375 IF YOU DO NOT RECEIVE THE TOTAL NUMBER OF PAGES. G`*I C01SIN1304TIALITY NOTICE; This fax transmission may contain confidential Information belonging to the sender and such h-iformatlon Is legally privileged and Is Intended only for the use of the individual or entity named above. Any copying, disclosure, z c!I!arll3utl0n or dissemination of this Information or the taking of any action based on the contents of this communication is strictly f i ' prohibited. if you have received this transmission In error, please notify us Immediately by telephone and return the original f � ,`i t ins;nlsslon to us by mail or delivery at our address above. We shall cover the cost of return mall. Thank you! t �h9� ',', e rF1G �''C08/'TUF 10; 56COMM 1:IRE DEPARTMENT FAX No, 5087902385 P, OC2 i !9 MM DD YYYY ®Delete i0xrs�^0_� U 12 I'2008 �J I0l3-0003596 I 000 ❑change �u:S`:r. ;k'Yt7p:: `-�, State Incident Date Station Incident M=X)Qr * Exposure ❑No Activity ' ❑chick this boy;to Indicate that trio adds...for this incident is Provided on the nidlaa4 zu. tl i fT• �„ �i��,.�j. tttd•.jlo zn eceCton B "Alternative Lo tioa spacifieeeion•. Us¢ only for Wildland fires. Census Tract ' 1— f "SY u .j u 1046I ' f ImAiN 6T ' r (; crr t-rztecticr, `---� - L„� L_ __J Puber/Milepost Prerix Street or xigzway Street Type Sul r=r •• 3 I i •" i; _ �__� I OSTERVILLE _Ik_ki 102655 1 yeatr W State Zip coda ( f t -- ,�_ Apt./Suite/Room City p -cant tc ! ' ' 4rea4aona I �w • Cross street or directions. as a 11eaDla - r1 T11 r' Midnight is 0000 ,II.elesit ype � � Date & Times F,2 Shift & 1�l-ii::`ns t t 1 Local option �.�I.: �� 9 !?11 +�r other combuftible 11clu d1 cnaek poxes if Month Day Year Er Min sec ! -- darea are the �� � � ( Iri1 :c/iR same as Alarm ALARM alvaye required !— 1 l._ Date. Alarm Stf 12 08 2008 18:58:47 I shift or Alarms DSet.,,lct': c3 Gi c ern or R®es i ved�r 1� � F18toon •t ARRIVAL required, unless canceled or did not arrive k {. ' .I1. tlia'� a:Ld received 1 I� 1 .., fJ �,rrivm] tk 12 08 ❑ 2008 L19:05:40 1 2d, ;—^Ii.Ivt4 ammzti4,, aid recV. Their FDID Their E3 e+% ,,i - state CONTROLLED Optional, Except for +aildland fires Special Studies l ald given arat.ic aid given I ®Controlled U U f I Local Option Is!r a:Ld given Their LAST rnCIT CLEARED, required except for wildland fires K .. Zneidont Number Last T3hit Speclal special. 2ir s_�)acna' ; 12 08 2008 I19:53:51 I Study ID6 study ❑ v:,iLt cleared L _..... ' ' :J:F r3iMSnns Taken �' G1 Resources G2 Estimated Dollar Losses 6t Va:li:e,' ElChock snit box and skip this : Its yOSSES gained IOT all U s!Urea it known. Optionl Section if an Apparatus or Personnel Loan 1= used. for non fires. 'None f S?e3 �;! [H&Z:krdous Materials .a ._ Apparatus Parsorulel Property $1 v 000 ,I 0001 ❑ 7llflD�y:?tt icn Taken {11 Suppression Contents $1 �� , 000 /1 000 ❑ l$F b 0001� I 0003I '{:4cl,,- stil}1C:icu Taken 12) - MdS PRE—INCIDENT V&LUE, Optional. Other I 0002 0004 k+ 3 Pr ®r I 000 000 I op tY $1 / I +�,� :11Ait 4al ltcticn 71Y.en (3) Check: box if resource counts ❑ include aid received resources. Contents 000 00J0 �xP .ad ]1elodulea �jl Casualti®g�None H3 Hazardous Materials. Rol®ass Mixed Use Pro le :¢ ty h A9AT Not Mixed Deaths Injuries N None � ❑ 10 Assembly use t. I.::.J`'"' ,�a-:'s Fire l� 1 ❑Natural Gas: .�.,im,k. .,avn..u.n or eazM.e.cr3... 20 Lducatioti use Sarvxce 2 ❑Propane gas: czi xb. t.ra (..in It—esQ grill) 33 Xedical use .-5 L 3 ®Gasoline: a 40 eidential u:at6: Caa C:iv'slian e fuel uax ex •�i.c®taiacs - A 51 Raw of..stores . 1'�r� :10:• t! 4 ❑'iter09er1g_ eu.i basin,,.galye�t or P-.t Itx.stanym K2Detectoa: 53 Inclosed mall �, tE'�'•, "� Repaired for ConLined F%rea. 5 ❑Diesel fuel/4'vel oi1:,Qhinle fuel vna nr partAal. 58 Bun. & Rrsiden-eial E 'I_VAL �d :FLre-8 6 ❑Household solvents: 1pa,/.f�ice apiil, oleanup.nay JP9 Office use -=' , u `�' ]. ooaupan De`.ecmr alerted t. : ❑ 60 Industrial use I '�1a_t acus-9 7 []Moto= oil: srea engine.r p.a ox......— use 2 Deteoi.r id not alert them r i 63 Milit�Y 1>?�. ao; d I . ❑ 8 a psi.=❑Paint: � man. Wt.15ag G 56 galloon 65 Fate use E° ` y� Ulf.' lf =:L [J�umxnoron 0 ❑ ��_vCes�•� �Fx >�+•- 00 Other ^nq••d use other: ��.s aaQeirefl.e u>> �.l:pt 1."tp 3ezrtt Use* structurea 341®Clinic,alini-c type infirm&tY 539 ❑Household goods,sales,repaixei "! v u-te? 342❑Doctor/d®nti 3t office 57 9 ❑Motor vehiclo/boat a ales/rapai i 6'. !�} rlrc21, :glace of worship 3610Prison or jail., not juvenile 571CIGas or Service stacioa Krst-a nswclrlt or cafeteria 419®1-or 2-family dwelling 599:0 Business office 3a /T�avexu or xlightclub 429®hAa]ti-family dwelling 615.❑Llectxic generating plant '1'1 Ie sS�7Lc mentary school or kindergarteri 43 9❑Rooming/boaxding house 629 ❑Laboratory/science lab 1 I ¢ „?! L' Vh saboal or junior high 449❑Commercial hotel or motel 700 ®manufacturing plant 1 "E'_ Cc3leige, adult education 459®Residsrlt.ial, board and Care 819 E]LIvestock/poult.ry storage(bvrri) I U i_' ❑ t:e Facility for 4he aged 4 64❑Dormitory/barraaks 882 ❑Non-reai�l2?al parking garii�:ra+ It> d eL�il:al 519❑Food and beverage sales 891 ®Warehouse }.'W LL ,E �- de - 936❑Vacant lot 981 El Construction site '. Aayarround or park 938 ❑Graded/care for plot of land 984 ❑ Industrial plant yard or orca—d 946 []Lake, river, stream peokup and enter a Property use code only a �fta_ea:.: (timberland) 951 ®Railroad right of way you have NOT checked a Property.vse box: i_.clrtcu atosage area 960 ❑Other street Property Use eaip or ts:anitasy landfill 961 ❑mighway/divided highway f Dual-ness o ,e fron lewd or field 96� ❑ResiBsntial a•creet/®.rAveway f) IL.7_WF Er ...m• - � s-1 * vis'o P. } � V r - 4 f -1 �F !s mein lz/oizoo oe-07oa�gel 1 f r! �ti , P:is jI 1-':C C-912CHITUE 0: 5o OOMM FIRE DEPARTMENT FAX I�To, 5087902385 P. OC3 ec1. .Pia.rc [1',±atty involved L--J—� OstLon Business nave (If applicable) area code Phone Number { { Ctcck$9h'_s Hox 3e Frs. c1rsG Name IeI Last Name suf-f.i_Y lF} ir�Sdect !the ioa. I I L.� L,_ I I'�"1 L'Rnn sl;;�!the throe J ,E CU,i7liGite ad J;:Ca9 ,1 �! 11Yiea:"6'a ur�eX Prefix Street or Rlggvaly I Street Type 3niftr. Apt./Suite/Room City !!tt �ri , Post Office Sox y } i L—j ( �I r State ZIP Code "people ±nvolvofl? Check t2iis box and attach Supplemental Forma (NFIRS—IS) as necessary {;, d Csstte as Person involv®aa I 7 �l then cheek this box end snip Vie rest of this eection- {>a„iy1� ;ou Bu5lbess name (if Applicable) Ares Code Phone Nu7aber - n E.f 61 ie6K L3 bo If Hr-,Ms-, H.ta. £Stet Names MI bast Name � - _ 3u1PSs sL, } was 9 I uid L�J I a R t the three r � B,lPIL p1� tp addl:cas Number S_e£ir. Street or gignvay Stzeoc syP o Buff�.: {.. Post office Box Apt,/Suite/Room city j �•.! r Ei)cli State ZIP Code ... ,oI-�S �O::Cicn .n 1d (' .i 1�(GLTIE BPD Jt:_{1« ; {PrryLpo�ne. PLT 31 mot) ; ` 2 c` O!Sb(yi; 2008/12/08 19:05:40 —. 325 AT EVENT MANNING IS 3 I sct cr yy 1.; 2006/12/08 19:08:26 — 321 AT EVENT MANNING IS 1 2008/12/08 19:08:28 — 306 AT EVENT MANNING IS 4 a c:•_ec:sk i { 2006/12/08 19:00:35 IUr111111�61i� P'�tOBLEM — DRIVER OF DAVIS TOW TRUCK 2008/12/08 19:02:06 rRFFORrING NOW AN MVC lity ; 0 2008/12/08 19:05:46 1 t lA 'COvJ TRUCK c.ctsF. i',; 2008/12/08 19:08:11 i?,2ii C�TI FOR 2 306 AVAILABLE � C i kl 2008/12/08 19:14:14 N. "C., NTAINING HYDRAULIC FLUID LEAK { 'c.-fc t;y'' ; 2008/12/08 19.21:27 , 84•d0 I I TAVARES, JOHN M. I ILT ( I J 2 08 �2sJU8� position nmcn or rank Aesigt Month Day Tea:: II �1 ki:,ICec ip a S charge. 1D signature 2 - ZU(�^ Position or rank Assignment - Monti Day Year t'sebe =0:ing regott ID Signature I 1 nio7n 12/nR/2nOR 00-000_;596 _.Sit f L Es ;9%2(.O8/TUE 10: 57 COMM FIRE DEPARTMENT FAX No, 5087902385 P, 004 MM DD YYYY complete u� I U �2 U 2008 � 2 1 08-0003596 000 Narrative'�� fI` ri'• F 5rate Inciflent Data Station rAeiflenc Number Exgoaure C+a T J�TaAi.e BPD IFrils( '"hone - PLT 2008/12/08 19:05:40 - 325 AT EVENT MANNING IS 3 }Ye,.Cf2 1 ; 2008/12/08 19:08:26 - 321 AT EVENT MANNING IS 1 rrrc5" ; 2008/12/08 19:08 :28 - 306 AT EVENT MANNING IS 4 1 p� 1 1991 2008/12/08 19.00:35 xe� nT UDf3N� PROBLEM - DRIVER OF DAVIS TOW TRUCK '1 1 rc,_ w 2008/12/08 19:02:06 -.,I, rj IORTING NOW AN MVC 2008/12/08 19:05:46 rub T(YQ' TRUCK I 1c t� !t ; 2D08/12/08 19:08:11 Fil�f3 0 K FOR 2 306 AVAILABLE e �y I � 2008/12/08 19:14:14 1� 30+ N`1.'ATNI_NG HYDRAULIC FLUID LEAK jrf:_) �'JADt ' ; 2008/12/08 19:21:27 k30 7 63'I TED 1 12c0�1008 20:45:32 7tavares tthe above; Upon investigating the vehicles at the MVA the flat bed invloved had its• �vr:a�s ]..c: fliud tank struck and was leaking the contents. The tank Contained 15 gallons of t ' .ic oil an we were not able to secure it. A dike of.speedy dry was placed 'arround th'a cx ��61'.c) contain it and to protect a nearby catch basin. Approximately 4-5 bags of sppedy a4; used to absorb the spill. The contaminated absorbant wes reclaimed by the tow truck carip l ytin.volved(Davis) and they were to dispose of it properly. Dispatch was instructed to 2.1 peritivent notifications according to dept policy and all notified did not feel the ,..� ; rya �a/ be at the scene. Le absorbant was reclaimed and the vehicles secured we cleared the scene. sr,I;14�5�.J :I Iivloved INk+r , TDie.sel flat bed tow truck MA repair plate 2574 m ,t da.n YA 75MN83 vin yvlts94d211190088 J. 4�ilk,1: 1 G + yy 4, 01920 1.2i08/200e 08-000J596 I �F �9/2(,08/TUE 10; 5'7 COMM FIRE DEPARTMENT Fh' No, 5087902385 P. 005 MM DD YYYY - 7, + ;1920 I�j L12181 1 2008 2 08-0003595 1 L 000 ] heists 2}BSRe) - 7-1 'a f{, State incident Date Station Incident Number Exposure * EEL No* ❑Change ga"Ld''lL "'fit wit ID chemical it hydraulic fluid 1993 I 30 000000000 Name Mr vunber _ DOT lra8ar'd CAS Registration Vumber [}. f claaaification phya3cd]. stiffs, #�`t a ner `lti�1✓e �2 Estimated container Capacity DI Estimated Amount Released �1 When Ralaekso8' i 1 Elsol±d s.' jCapacity: by volume or weight Amount released: by Volume ox we]gnt 2 ®Liquid :1�i ]i rasher T}A a 3 ❑Gas : C3 Units' Cagaaity D2 Units: Released U ❑Undetermined ) Check one box ' t Check one Doi 1 RtOLYJME WEIGHT VOLUME WEIGHT _ - T, ;•--- 11 ❑OUTICSS 21 ❑ounces 11 ® ❑Ounces 21 ounces F12 Released trito c; 'P3a q hatardou. 12 NGallons 22 OR—ds 12 ®Gallons 22 ®Pounds _al.a? Usa 13 ❑Barrelet 42 gal. 23 ❑Grams 13 ❑Barrels: 42 gal. 23 El Grams E �{°'e;;ij, tt�q (bnal she to. 14 ❑Liters 24 ❑Kilograms 14 ❑Liters 24 ❑Kilograms L 8 L "It 1 NC.'4!I: 15 Cubic feet Released into ❑ 15 ❑Cubic feet f �;yi - 16 ❑Cubic meters 16 ❑cubic meters F2 Population DensitY G2 Area Evacuated None HazMat Actions Taken not a 'J,thQ, 1.18maindar Enter tap to three actions taken ,1 a£,pr. only for true I .I S;Ir 1 4e d:.ua material 1 �mgpi I tf a.�. ❑ 1 ® Square Feet ,�J 13 ( IHazwat spill control,�l g !]n4D�.ye ' [I tLSB 1A;,},t:f1RT-. ,a 2 ❑ Suburbaa 2 Blocks Enter primary Reciop Takao (1) 11ra1 Idrzasurement 3 ❑ ,3� ❑ Square miles L� 7,( Estlmated Number of IN i;. $ S'GYaL.: G3 AAflitional Action Taken (2) !� '0! G Pe le Evacuated 1 Area Affected oP rpliu:ble boxes I l _ + !� ®, � sue! Additional Action 'taken (3) j( �( �> ctz"3rsads 1 ❑ Square Feet •' s�i d is involved<ith losioa Is 'I 2 ❑ Biooke Estimated Number of Ir rlra or][ �. L � iCle/:Ii ECrl1C't71r0€ G� Telesis, L+hieh orivrrad first? ',•`�!l - 3 ® Squar miles Buildings Evacuated , Stony of t. I I ' I f� 1 ❑igni.tion U ❑Undstexmiz ed `� r !)It.� Rcloaee L•--� a--- R. 2'k,i Sale of utructur , i ®ISon® 2 ❑Rclesae Enter meaeuremenic pie Of Relea a Factors Contributing t o Release Factors Af£Qeting D�itigati.on Enter up to three contributing factors Enter up to three fact=eQ Or lmpedlments tryst affected the mitigation of the incidentaircional .3 2p ]t ou°4nnal release NN loons �71 1 lcoilision, overturn, knockdowwn J I NN I ° ;Iy;•�(, Factor contributing To Aeleass (1) Factor or impediment (1) 'i m - j nment ffaaluxe 1 ' Er a 6f ::nayure k J li 11]ider veatigation Factor Contributing �'o Release (Zl factor or impediment (2) ICt3�a.3a uaa�atersinmd enter ' f Factor contributing To Raleaze (3) Factor or impediment (31 Et 4 ® HarMat: D1SpoSition*, t. i +IJ �a in€lait Involved In Release N %bile Prop®rtgv Involved ®Norse l , l" Xn Release 1 ®Completed by fire service only r (t f I;sj1 ❑None 2 ❑Co>aplet®d w/ f�rg eerviae 63 Loader - industrial, fork ( resent II �rPr9iwt]lia equipment, 3 'Released to local agency aa. ,lt G s -I �_— - [Mobile property tyre 1 c( _z'1A.v)lvecl in release a 4 I 4 ®Released to county agency NI jlqissanMobile property make 5 []Released to stateagonaX ar;� i sae�aa 6 ❑Released to federal agency JUN XNOWN 1111 7 ®Releaaad to a private agency 4' �!•;1 dE ).i_t :ned tow trilck ( Mobile property m Year Mbl et model 8 ®Released to property awner ip �p��, (� . 12574M I )--- or mana „1IcnWvrn 4 )[L).cer)sa slate number state ® g€az aat Civilian Ca&umlt9.e-%�' 71•itd''I I ? " Deaths Injvz�ea sill lunknowra >i{4i.• i{ th,,,## a DOT Nmberl ICC Nturber I Ij y a i i1S�r.t�� t li � � kl � � {! YdL IR@-7 Ifavisioan 5/6/'e,e1 r. nia1>n 1�rnnionnu na=nnnt,os :, t. 4V:f. YOU WISH TO OPEN A BUSINESS? For Your.Information: Business certificates (cost$40.00 for 4 years). A business certificate ONLY REGISTERS YOUR NAME in town (which-you must do by M.G.L.-it does not give you permission to operate.) You must first obtain the necessary signatures on this form at 200 Main St., Hyannis. Take the completed form to the Town Clerk's Office, 1 st FI., 367 Main St., Hyannis, MA 02601 (Town Hall) and get the Business Certificate that is required by law. DATE: /��5 Fill in please: `4' w APPLICANT'S YOUR NAME/S A � � BUSINESS YOUR HOME ADDRESS: ei TELEPHONE # Home Telephone Number NAME OF CORPORATION: V NAME OF NEW BUSINESS TYPE OF BUSINES IS THIS A HOME OCCUPATION? YES X NO ADDRESS OF BUSINESS t1�/ MAP/PARCEL NUMBER (Assessing) When starting a new business there are several things you must do in order to be in compliance with the rules and regulations of the Town of Barnstable. This form is intended to-assist you in obtaining the information you may need. You MUST GO TO 200 Main St. — (corner of Yarmouth Rd. & Main Street) to make sure you have the appropriate permits and licenses required to legally operate your business in this town.,; 1. BUILDING COMNIISSIO ER'S OFFI This individ�laI ha e in for m o a y p mit qu'reme s hat pertain to this type of business. i->� - ut rized Sign tur COMMENT (zk� 2. BOARD OF HEALTH This individual has been informed of t rm' equirements that pertain to this type of business.- MUST COMPLY WITH ALL HAZARDOUS MATERIALS REGULATIONS Authorized Signatur COMMENTS: 3. CONSUMER AFFAIRS (LICENSING AUTHORITY) This individual has been informed of the licensing requirements that pertain to this type of business. Authorized Signature* COMMENTS: kk TOWN OF BARNSTABLE TOXIC AND HAZARDOUS MATERIALS REGISTRATION FORM NAME OF-BUSINESS: BUSINESS LOCATION: 7 INVENTORY MAILING ADDRESS: TOTAL AMOUNT: TELEPHONE NUMBER: ) CONTACT PERSON: -rVc:c?}C EMERGENCY CONTACT TELEPHONE NUMBER: — . 2(off MSDS ON SITE? TYPE OF BUSINESS: �?Ah) + �m►n � ,� INFORMATION / RECOMMENDATIONS: Fire District: Waste Transportation: Last shipment of hazardous waste: Name of Hauler: Destination: Waste Product: Licensed? Yes No NOTE: Under the provisions of Ch. 111, Section 31, of the General Laws of MA, hazardous material use, storage and disposal of 111 gallons or more a month requires a license from the Public Health Division. LIST OF TOXIC AND HAZARDOUS MATERIALS The Board of Health and the Public Health Division have determined that the following products exhibit toxic or hazardous characteristics and must be registered regardless of volume. Observed / Maximum Observed / Maximum Antifreeze (for gasoline or coolant systems) Miscellaneous Corrosive ❑ NEW ❑ USED Cesspool cleaners Automatic transmission fluid Disinfectants Engine and radiator flushes Road salts (Halite) Hydraulic fluid (including brake fluid) Refrigerants Motor Oils Pesticides ❑ NEW ❑ USED (insecticides, herbicides, rodenticides) Gasoline, Jet fuel,Aviation gas Photochemicals (Fixers) Diesel Fuel, kerosene, #2 heating oil ❑ NEW ❑ USED Miscellaneous petroleum products: grease, Photochemicals (Developer) lubricants, gear oil ❑ NEW ❑ USED - Degreasers for engines and metal Printing ink Degreasers for driveways&garages Wood preservatives (creosote) Caulk/Grout Swimming pool chlorine Battery acid (electrolyte)/Batteries Lye or caustic soda Rustproofers Miscellaneous Combustible Car wash detergents Leather dyes Car waxes and polishes Fertilizers Asphalt& roofing tar PCB's Paints, varnishes, stains, dyes Other chlorinated hydrocarbons, Lacquer thinners (including carbon tetrachloride) ❑ NEW ❑ USED Any other products with "poison" labels (including chloroform,formaldehyde, Paint&varnish removers, deglossers hydrochloric acid, other acids) Miscellaneous. Flammables Other products not listed which you feel Floor&furniture strippers may be toxic or hazardous(please list): Metal polishes k ^ Laundry soil &stain removers (including bleach) Spot removers &cleaning fluids (dry cleaners) Other cleaning solvents Bug and tar removers Windshield wash WHITE COPY-HEALTH DEPARTMENT/CANARY COPY-BUSINESS Appl s Signature Staff's Initials 6 v Date , Physical Street Address-Check database to ensure it exists v orking Phone Number /Actual Amounts -( ie. gas being used to fuel machines, thinner to /clean brushes all count as hazardous materials-no blanks) v Storage Information -location of storage, how long is storage for? J If none, note that. ��isposal Information -where and who? If none, note that. ✓ Applicant Signature - understand.what is listed and noted ,Staff Initial -any questions, know who to ask ✓Vehicle Washing/Rinsing? -give a vehicle washing policy and / explain it Attach the Business Certificate with your sign off and comments "The inventory form should explain what the business consists of and the procedures they are doing. Notes need to be left to explain what you discussed with them. ht SGUA i w r I it�hn s �.r u�- a Au avid- wi(I mf j�)tI Sim o-0-�'OtUJ YOU WISH TO OPEN A BUSINESS? > For Your Information: Business certificates (cost$40.00 for 4 years). A business certificate ONLY REGISTERS YOUR NAME in town (which you must do by M.G.L.-it does not give you permission to operate.) You must first obtain the necessary signatUres on this form at 200 Main St., Hyannis. Take the completed form to the Town Clerk's Office, 1 st FL, 367 Main St., Hyannis, Iv1A 02601 (Town Hall) and get the Business Certificate that is required by law. DATE: '_ r Fill in please: d APPLICANT'S YOUR NAME/S: �/ BUSINESS YOUR.HOME ADDRESS: S k ��c� ���� TELEPHONE # Ho Telephone Number `-�rS - FRS- �6-)0 NEW BUS NESS no �0, '� G.fYI rGvn E( TYPE OF BUSINESS NAME OF : IS THIS A HOME OCCUP,TION - YES;' NO y ADDRESS,OF:BUSINESS�b e MAP/PARCEL NUMBER :I O« O( �(Assessing) When starting a new business there are several things you must do in order to be in compliance with the rules and regulations of the Town of Barnstable. This form is intended to assist you-in obtaining the information you may need. You MUST GO TO 200 Main St..- (corner of Yarmouth Rd. & Main Street] to make sure you have the appropriate permits and.licenses required to legally operate your business in this town. 1. BUILDING COMMISSIONER'S OFFICE This individual has been informed of any permit requirements that pertain to this type of business. Authorized Signature** COMMENTS: 2. BOARD OF HEALTH This individual has been- m inn red of the permit requirements that pertain to this type of business. MUST,,4MPLYWITH ALL R'AZARDOUS MATERIALS REGULATIONS Authorized Signature** COMMENTS: 3. CONSUMER AFFAIRS(LICENSING AUTHORITY) This individual has been informed of the licensing requirements that pertain to this type of business. Authorized Signature** COMMENTS: Date:/Of//0Z 1'wd TOWN OF BARNSTABLE TOXIC AND HAZARDOUS MATERIALS ON-SITE INVENTORY NAME OF BUSINESS:" ,j! o, cIYk c. BUSINESS LOCATI( INVENTORY MAILING ADDRESS: )mi C, uIAC� TOTAL AMOUNT: TELEPHONE NUMBER: C-Ngp� 6 e>_-s-�SOS CONTACT PERSON: ] yy00NP, EMERGENCY CONTACT TELEPHONE NUMBER: C-M) 6Ss1669 MSDS ON SITE? TYPE OF BUSINESS: 4 C77_01V- INFORMATION/RECOMMENDATIONS: Fire District: Waste Transportation: Last shipment of hazardous waste: Name of Hauler: Destination: Waste Product: Licensed? Yes No NOTE: Under the provisions of Ch. 111, Section 31, of the General Laws of MA, hazardous material use, storage and disposal of 111 gallons or more a month requires a license from the Public Health Division. LIST OF TOXIC AND HAZARDOUS MATERIALS The board of health and the Public Health Division have determined that the following products exhibit toxic or hazardous characteristics and must be registered regardless of volume. Observed / Maximum Observed / Maximum Antifreeze (for gasoline or coolant systems) Miscellaneous Corrosive ❑ NEW ❑ USED Cesspool cleaners Automatic transmission fluid Disinfectants Engine and radiator flushes Road salts (Halite) Hydraulic fluid (including brake fluid) Refrigerants Motor Oils Pesticides ❑ NEW ❑ USED (insecticides, herbicides, rodenticides) Gasoline, Jet fuel,Aviation gas Photochemicals (Fixers) Diesel Fuel, kerosene, #2 heating oil ❑ NEW ❑ USED Miscellaneous petroleum products: grease, Photochemicals (Developer) lubricants, gear oil ❑ NEW ❑ USED Degreasers for engines and metal Printing ink Degreasers for driveways&garages Wood preservatives (creosote) Caulk/Grout Swimming pool chlorine Battery acid (electrolyte)/Batteries Lye or caustic soda Rustproofers Miscellaneous Combustible Car wash detergents Leather dyes Car waxes and polishes Fertilizers Asphalt& roofing tar PCB's Paints, varnishes, stains, dyes Other chlorinated hydrocarbons, Lacquer thinners (including carbon tetrachloride) Any other products with "poison" labels _�❑ NEW-_ 0 USED_. _ (including chlorofor ►,forrnaldehyde._ _ _ Paint&varnish removers, deglossers hydrochloric acid, other acids) Miscellaneous. Flammables Other products not listed which you feel Floor&furniture strippers may be toxic or hazardous (please list): Metal polishes Laundry soil &stain removers (including bleach) Spot removers &cleaning fluids (dry cleaners) Other cleaning solvents Bug and tar removers Windshield wash s WHITE COPY-HEALTH DEPARTMENT I CANARY COPY-BUSINESS App. - ature Staff's Initials COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION V� TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 1046 Main Street /f Osterville , Owner's Name: Village West Condo's Owner's Address: P.O.Box 86 Centerville,MA 02632 ��— Date of Inspection: 5/16/2006 Name of Inspector: (please print) Patrick T. Sullivan Company Name: Ready Rooter Mailing Address: P.O.Box 371 Sandwich,MA 02563 Telephone Number: (508)888-6055 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The System: Passes Conditionally Passes Needs Further Evaluation by the Local Authority Fails Inspector's Signature: Date: The system inspector shall submit a copy of this inspection report to the Approving Authority,(Board of Health or; DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regibnal offiee'of the", DEP. The original should be sent to the system owner and copies sent to the buyer,if applicable,end the approving authority. t Ci rn Notes and Comments ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. Page 2 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 1046 Main Street Osterville Owner: Village West Condo's Date of Inspection: 5/16/2006 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: One or more system components as described in the"Conditional Pass"sectio need to be replaced or repaired.The system,upon completion of the replacement or repair,as approved by a Board of Health,will pass. Answer yes,no or not determined (Y,N,ND)in the for the following tements. If"not determined"please explain. The septic tank is metal and over 20 years old*or the septic (whether metal or not)is structurally unsound,exhibits substantial infiltration or exfiltration or tank failure s imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved the Board of Health. *A metal septic tank will pass inspection if it is structurally so� not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. , ND explain: f` i Observation of sewage backup or break out or h4g'hh static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): broken,pipe(s)are replaced obsstr fiction is removed di ution box is leveled or replaced r ND explain: Ef The system required pumping mp�re than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: Page 3 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 1046 Main Street Osterville Owner: Village West Condo's Date of Inspection: 5/16/2006 C. Further Evaluation is Required by the Board of H h: Conditions exist which require further evaluationthe Board of Health in order to determine if the stem �l Y system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Healt (determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a mannerhich will protect public health,safety and the environment: Cesspool or privy is within 50 fet of a surface water Cesspool or privy is within 54 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the system is functioning in a manner that protects the public health,safety and environment: _The system has a septic tank and soil absorption system(SA and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. —The system has a septic tank and SAS and the--;SAS s within 50 feet of a private water supply well. The system has a septic tank and SAS and th S is less than 100 feet but 50 feet or more from a private water supply well**. Method used to dete r ne distance **This system passes if the well water analysis, rformed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates t the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate mgen is equal to or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the anal is must be attached to this form. j I 3. Other: r rj Page 4 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 1046 Main Street Osterville Owner: Village West Condo's Date of Inspection: 5/16/2006 D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all inspections: Yes No Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ✓ Static liquid level in the distribution box above outlet invert due to and overloaded or clogged SAS or cesspool Liquid depth in cesspool is less than 6"below invert or available volume is less than'h day flow Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped . Any portion of the SAS,cesspool or privy is below high ground water elevation. -Z Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface / water supply. y* Any portion of a cesspool or privy is within a Zone I of a public well. _ _� Any portion of a cesspool or privy is 50 feet of a private water supply well. 2-Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form.] LD(Yes/No)The system fails. I have determined that one or more of the above criteria exist as described in 310 CMR 15.303,therefore the system fails.The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large Systems: To be considered a large system the system must serve gPd• a*cility with a design flow of 10,000 gpd to 15,000 / You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) yes no the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a Outary to a surface drinking water supply lF the system is located in a nitroon sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone 11 of a public water supply well a If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered "yes"in Section D above the largq, ystem has failed.The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner shopd contact the appropriate regional office of the Department. t f Page 5 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 1046 Main Street Osterville Owner: Village West Condo's Date of Inspection: 5/16/2006 Check if the following have been done. You must indicate"yes"or"no"as to each of the following: Yes No _jZ-_ Pumping information was provided by the owner,occupant,or Board of Health Were any of the system components pumped out in the previous two weeks? _jZ'_ Has the system received normal flows in the previous two week period? f Have large volumes of water been introduced to the system recently or as part of this inspection? a/*"_ Were as built plans of the system obtained and examined?(If they were not available note as N/A) v"' _ Was the facility or dwelling inspected for signs of sewage back up? V _ Was the site inspected for signs of break out? ✓ _ Were all system components,excluding the SAS,located on site? Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition of the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum? _ Was the facility owner(and occupants if different than owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: Yes No Existing information.For example,a plan at the Board of Health. _ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(3)(b)] Page 6 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 1046 Main Street Osterville Owner: Village West Condo's Date of Inspection: 5/16/2006 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): Number o bedrooms(actual): DESIGN flow based on 310 CMR 15/(last 203 (for ple: 110 gpd x#of bedrooms): Number of current resid Does residence have a gr(y or no):_ Is laundry on a separate es or no):_[if yes separate inspection required] Laundry system inspect _Seasonal use: (yes or noWater meter readings,ist 2 years usage(gpd)): Sump Pump(yes or no) Last date of occupancy: COMMERCLUJINDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): Basis of design flow(seats/persons/sq. ft.etc.): t Grease trap present(yes or no): Industrial waste holding tank present(yes or no):.%r Non-sanitary waste discharged to the Title 5 system(yes or no) Water meter readings,if available: 6 Dc�) (z, c;c�( 6.4— Last date of occupancy/use: c�s,►. ', - OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: 5i�L., - = �•`' Was system pumped as part of the inspection(yes or no):., 5f',) If yes,volume pumped: gallons--How was quantity pumped determined? Reason for pumping: TYP)F OF SYSTEM eptic tank,distribution box,soil absorption system Single cesspool Overflow cesspool Privy _Shared system(yes or no)(if yes,attach previous inspection records,if any) _Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) Tight tank _Attach a copy of the DEP approval _Other(describe): Approximate age of all components,date installed(if known)and source of information: �.�"��.,._ , °.�-5-'.��1� � �'�,�-�wle-�1 '1"�`�"� 'ems ��:�' ��►"�.. Were sewage odors detected when arriving at the site(yes or no):1_2a) Page 7 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 1046 Main Street Osterville Owner: Village West Condo's Date of Inspection: 5/16/2006 BUILDING SEWER(locate on site plan) Depth below grade: 0 r Materials of construction:_cast iron_40 PVC other(explain): Distance from private water supply well or suction line: N/A Comments(on condition of joints,venting,evidence of lea age,etc.): SEPTIC TANK: (locate on site plan) Depth below grade: r `6 Material of construction:Zconcrete_metal_fiberglass_polyethylene _other(explain) If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of certificate) Dimensions: Sludge depth: 3" Distance from the top of sludge to bottom of outlet tee or baffle: 3 Scum thickness: & `r Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: How were dimensions determined: Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structdral integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): �e3c C�.A,..w.o-.L✓�.K+ i�lCJaw'.i�� �ICaraJV``y1 ��U „�yV��i2A. L�.�iu`' K1��'�C '�"J�'C"J�' l�CSI� ��-'�. �- t✓ Gr+ .d�n.c � 'L.1�� �`�rf C" l'm ��cP :�Y�l iX� �ZiV'�-r ��• C9 rJ �� 'y��,,�.+sS:.P"'r. � M.�1e�a� G.G7r.J'�S� `e4T"C� �0 Z'a v� j� GREASE TRAP:_(locate on site plan) Depth below grade:_ Material of construction:_concrete_metal___Pb rglass_polyethylene_other (explain): Dimensions: Scum thickness: Distance from top of scum to top of outl/n1e e: Distance from bottom of scum to bottom or baffle: Date of last pumping: Comments(on pumping recommendatiet outlet tee or baffle condition, structural integrity,liquid levels as related to outlet invert,evidence of le f '� f Page 8 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 1046 Main Street Osterville Owner: Village West Condo's Date of Inspection: 5/16/2006 TIGHT or HOLDING TANK: (tank mus/bbe umped at time of inspection)(locate on site plan) Depth below grade: Material of construction:_concrete_me fiberglass polyethylene_other(explain): Dimensions: Capacity: gallo Design Flow: gall s/day Alarm present(yes or no): Alarm level: Alarm in rking order(yes or no): Date of last pumping: Comments(condition of al and float switches,etc.): DISTRIBUTION BOX:_1z'(if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: Comments(not if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakage into or out of box,etc.): l c cs �•;yv--. �-�'r- r�-,.�t,,�-.��:, ;�.�--via 1, �pt��.�- -vca �,•�.�Q�., PUMP CHAMBER: (locate on site an) Pumps in working order(yes or no): Alarms in working order(yes or no): Comments(note condition of pump amber,condition of pumps and appurtenances,etc.): Page 9 of 11 . OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 1046 Main Street Osterville Owner: Village West Condo's Date of Inspection: 5/16/2006 SOIL ABSORPTION SYSTEM(SAS):—Izoocate on site plan,excavation not required) If SAS not located explain why: Type �eaching pits,number: CA leaching chambers, number: leaching galleries,number: leaching trenches,number,length: leaching fields,number,dimensions: overflow cesspool,number: innovative/alternative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation, etc.): AJ4 .i��,e• • n CESSPOOLS: (cesspool must be pumped part of mspection)(locate on site plan) Number and configuration: Depth—top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater infl (yes or no): Comments(note condition o soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): PRIVY: (locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments(note condition of soil, S. s of hydraulic failure,level of ponding,condition of vegetation,etc.): Page 10 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 1046 Main Street Osterville Owner: Village West Condo's Date of Inspection: 5/16/2006 SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks.Locate all wells within 100 feet. Locate where public water supply enters the building. 7 arz 1 o Zq $ 37 o o Page 11 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 1046 Main Street Osterville Owner: Village West Condo's Date of Inspection: 5/16/2006 SITE EXAM Slope Surface water Check cellar L,-- Shallow wells Estimated depth to ground water feet Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record—If checked,date of design plan reviewed: fL Observed site(abutting property/observation hole within 150 feet of SAS) Checked with the local Board of Health-explain: Checked with local excavators,installers-(attach documentation) _Accessed USGS database-explain: You must describe how you established the high ground water elevation: n _' �� e .u�.� � c:�J— '� ram• ._-. -r � � �- �.1`�-=� � S� �•. ���c.s�'�•��. c\Gl �LC ;_l�.e. L�_�,��5{•c�c�� �X�'7�r3.n��.� •ea • ; � �iF�..ly. f COMMONWEALTH OF MASSACHUSETTS ' EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENT RQTFG RECBV ' JUN U ,2 2004 TOWN OF BARNSTABLE HEALTH DEPT. TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS ' SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 1046 Main Street MAP Os tervi l le. .MA PARCEL Owner's Name: Village West Condo Assoc Owner's Address: tiQ7 Date of Inspection: Name or .lnspector.(please print) W i 1 1 i am _ . Roh i n son Sr. Company Name: William E. Robinson Septic Service MAlinRAddress: P O Box 1089 Centerville. MA Telephone Number:_(5 0 81 7 7 5—87 7 6 CERTIFICATION STATEMENT 1 certify that 1 have personally inspected the sewage disposal system at this address and that the information reported . below is true,accurate and complete as of the time of the inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems.I am a DEP approved system inspector pursuant,toySecon 15340 of Title 5(310 CNIR 15.000). The system: t/Passes Conditionally Passes ` Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature:� Date: ' The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health•or DEP)within 30 days of completing this inspection.If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving authority. Notes and Comments •"This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. Title 5 Inspection Form .6h 5/2000 page 1 Page 2 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 1046 Main Street Osterville, MA Owner. Village West Condo Assoc Date of Inspection:_ v Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. Sy m Passes: l have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: System Conditionally Passes: One or more system components as described in the"Conditional Pass"section need to be replaced or repa ed.The system,upon completion of the replacement or repair,as approved by the Board of Health;will pass. Answ es,no or not determined(Y,N,ND)in the for the following statements.If"not determined"please explain. Th septic tank is metal and over 20 years old"or the septic tank(whether metal or not)is structurally unsound, ibits substantial infiltration or exfiltration or tank failure is imminent.System will pass inspection if the existing is replaced with a complying septic tank as approved by the Board of Health. •A metals tic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance in at the tank is less than 20 years old is available. ND explain: Obst rvation of sewage backup or break out or high static water level in the distribution box due to-broken or obstructed p ipe(s)or due to a broken,settled or uneven distribution box.System will pass inspection if(with approval of oard of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND expla' Th system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will pass inspe lion if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is rcmovod ND a lain: Page 3 of 1 I OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 1046 Main Street Osterville, MA Owner: Villa e .We t Condo Assoc Date of Inspection: r C. Further Evaluation is Required by the Board of Health: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is fail g to protect public health,safety or the environment. 1. ystem will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the ' ystem is not functioning in a manner which will protect public health,safety and the environment: Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. S stem will fail unless the Board of Health(and Public Water Supplier;if any)determines that the syste Is functioning Ina manner that protects the-public health,safety and environment: The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a s rface water supply or tributary to a surface water supply. The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. _ The system has a septic tank and SAS and the SAS is within 50 feet of'a private water supply well. _ The system has aseptic tank and SAS and the SAS is less;than 100 feet but 50 feet or more frond a private water supply well•• Method used to determine distance . ••This system passes if the well water analysis,performed at a DEP certified laboratory,for coliforn bacteria and volatile organic compounds indicates that the well is Gee from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. 3. `Other: t 3 z Page 4 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 1046 Main Street Osterville, 'MA Owner: Village West Condo Assoc Date of Inspection: -- 6 D. . System Failure Criteria applicable to all systems: You us(indicate"ycs"or"no"to each of the following for all inspections: Yes No Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool Static liquid level in the distribution box above.outlet invert due to an overloaded or clogged SAS or cesspool _ Liquid depth in cesspool is less than 6"below invert or available volume is less than'/,day flow Required pumping more than 4 times in the last year.NOT due to clogged or obstructed pipe(s).Number of times pumped _ Any portion of the SAS,cesspool or privy is below high ground water elevation. y portion of cesspool or privy is within I00-feet of a surface water supply or tributary to a surface water supply. y portion of a cesspool or.privy is within a Zone I of a public well. _ kny portion of a cesspool or privy is within 50 feet of a private water supply well. y portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private Kairr supply well with no acceptable water quality analysis.(This system passes if the well water analysis, performed at a DEP certified laboratory.,for coliform bacteria and volatile organic compounds Indicates that(Ire H•cll is free.from pollution from that facility and(lie presence of ammonia nitrogen and nitrate titrogen is equal to or less than S ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form.) )arge s/No)The system fails.I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails.The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd• , You m t indicate either"yes"or"no"to each of the following: (llte fol owing criteria apply to large systems in addition to the criteria above) yes no to system is within 400 feet of a surface drinking water supply e system is within 200 feet of a tributary to a surface drinking water supply e system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped one 11 of a public water supply well If you ha4 answered"yes"to any question in Section E die system is crosidered a significant threat,or answered "yes"in 'ction D above the large system has failed.The tmmer or operator of any large system considered a significa threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. a system owner should contact the appropriate regional office of the Department. Page 5 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPE&ION.FORM PART B . CHECKLIST: Property Address: 1046 Main Street. Osterville, MA Owner: Villacte West Condo Assoc + Date of Inspection: j, Check if the following have been done.You must indicate' " • "no" . "— `yes or"no as to each of the following: - Yes No Pumping information was provided by the owner,occupant,or Board of Health �Wcre any of the system components pumped out in the previous two weeks? r/ Has the system received normal flows in the previous two week period? ! Have•large volumes of water been introduced to the system recently or as part of this inspection T. Were as built plans of the system obtained and examined?(If they were not available note as N/A). Was the facility or dwelling inspected for signs of sewage backup? Was the site inspected for signs of break out? Were all system components,excluding the SAS,located on site?. Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition . of the baffleess or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum?` _ _ Was the facility owner(and occupants if different from owner)provided with information on the+proper maintenance of subsurface sewage disposal systems? r The size and location of the Soil Absorption System(SAS)on the site has been determined based on: Yes , no/ . Existing information.For example,a plan at the Board of Health. , Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)13 10 CMR 15.302(3)(b)]' t. 5 Page 6 of 11 OFFICIAL INSPECTION FORM-NOT FOR VO LUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 1046 Main Street uster.vii1e, MA Owner: village WEst Condo Assoc Date of Inspection: — <- FLOW CONDITIONS RESIDE/1A Number oms design):. Number of bedrooms(actual): DESIGNase on 310 CMR 13.203(for example: 110 gpd x N of bedrooms): . Number n esidents: Does resive a garbage grinder(yes or no): Is laundryeparate sewage system(yes or no): [if yes separate inspection required] Laundry inspected(yes or no): Seasonales or noWater mdings,if available(last 2 years usage(gpd)): 2003 - 201 , 000 Sump pus or no):_ - 179, 00 Last date of occupancy: COMMERCIAIANDUSTRIAL Type of establishment: 5 Design flow(based on 310 C 15.203): gpd Basis of design flow(seats/persons/sgft,etc.): Grease trap present(yes or no):f�C� Industrial waste holding tank present(yes or no): LSO Non-sanitary waste discharged to the Title S system(yes or no):�c- Water meter readings,if available: Last date of occupancy/use: O e-� OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: Was system pumped as part of the inspection(yes or no):_ If yes,volume pumped: Qallons--How was quantity pumped determined? Reason for pumping: TYP�FOF SYSTEM c/�eptic tank,distribution box,soil absorption system _Single cesspool Overflow cesspool Privy _Shared system(yes or no)(if yes,attach previous inspection records,if any) _Innovative/Altemativc technology.Attach a copy of the current operation and maintenance contract(to be obtained from system ow ner) caner Y ) _Tigbt tank Attach a copy of the DEP approval _Other(describe): Approximate age of all components date. stalled(i known)and source of information: �n d Were sewage odors detected when arriving at the site(yes or no):k 0 6 Page 7 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 1046 Main Street Osteryi e, MA Owner.Villa e West Condo Assoc ' Date of Inspection:_ —p BUILDING,/SEWR(locate onsite plan)Depth beloMaterialsoctioncast iron _40PVC_other(explain):Distance Gte water supply well or suction line:Commentsition of joints,venting,evidence of leakage;etc.): T SEPTIC TANK: L' locate on ' ..._( site Ian Depth below grade: _ - Materialofconstruction: concrete "—metal fiber 1 other(explam) . g ass_polyethylene If tank is metal list age: Is age confi med•by a Certificate of Compliance(yes or no): (attach a copy of certificate) i , , Dimensions: Sludge depth:_ — _ Distance from top of sludge to bottom of outlet tee or baffle: Li / Scum thickness: -eS _ i Distance from top of scum to top of outlet tee or baffle: I / Distance from bottom of scum to bottom of outlet tee or ba(l�e: �� How were dimensions detcrmincd: ��•.� G�, ���� Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): �6 CREASE T P:—(locate on site plan) Depth bolo grade: Material of onstruction:—concrete. metal r fiberglass_polyethylene other (explain): -- Dimension Scum thic*ess: Distance fjom top of scum.to to of outlet tee P or baffle: Distance ltom bottom of scum to bottom of outlet tee or baffle: Datc of list pumping: Comme s(on pumping reconunendations,inlet and outlet tee or battle condition,structural integrity,liquid levels as rclatc 10 outlet invcrt,evidence of leakage,etc.): Page 11 of l l OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 1046 Main Street s ervi e, Owner: Vi e WEst Condo Assoc Dale of inspection: 4 - 7,7! TIGHT or H LDING TANK: (tank must be pumped at time of inspection)(locate on site plan) Depth below gr dr. Material of cons ruction: concrete metal fiberglass polyethylene other(explain): Dimensions: Capacity. gallons Design Flow: allons/day Alarm present es or no): Alarm level: Alarm in working order(yes or no): Date of last p ping: Comments(c ndition of alarm and float switches,.etc.): DISTRIBUTION BOX:�/f present must be opened)(locate on site plan) Depth of liquid level above outlet invert: C) Commerts(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakage into or out of box,ctc.): I — PUDIP CHA MBE (locate on site plan) Pumps in workin order(yes or no): Alarms in worki g order(yes or no): Comments(no condition of pump chamber,condition of pumps and appurtenances,etc.): Page 9 of I 1 " OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 1046 Main Street s ervi e, M Owner: Village WEst Condo Assoc _ Date of Inspection:__ f-j!q -G, ` SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,excavation not required) If SAS not located explain why: " Typ leaching pits,number:ILI- leaching chambers,number: leaching galleries,number: ' leaching trenches,number,length: leaching field u s number, r dimen sions:ions:- overflow cesspool,number: innovative/alternative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation, etc.). - X � 2 7 � � V CESSPOOLS: (cesspool must be pumped as part of inspection)(locate on site plan) Number and config ation: Depth-top of liqui to inlet invert: ° Depth of solids layer Depth of scum layer: Dimensions of cessp ol: Materials of constru lion: Indication of groun ater inflow(yes-or no): Comments(note co dition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): PRIVY: (lo ate on site plan) y Materials of cons ction:_ Dimensions: Depth of solids: Comments(no condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): . 9 Page 10 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 1046 Main Street Osterville, MA Owner: Villacte 4gst, Condo Assoc Date of inspection: 5 ty—c9 SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks.Locate all wells within 100 feet.Locate where public water supply enters the building. �Y i L Qo z �1 1 10 Page I 1 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 1046 Main Street Osterville, MA Owner. Village e t Co do Assoc Date.of Inspection: y -b L SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water L feet Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record-If checked,date of design plan reviewed_: Observed site(abutting propertylobservation hole within 150 feet of SAS) Checked with local Board of Health-explain: ecked with local excavators,installers-(attach documentation) Accessed USGS database-explain: You must describe how you established the high ground water elevation: — ` 417, 11 Date: TOXIC AND HAZARDOUS MATERIALS REGISTRATION FORM NAMEOFBUSINESS: BUSINESS LOCATION: b 4(,o mlia , S ` MAILING AD ODRESS: ! �Y-y l I ma oa( c--�;— Mail To: Board of Health TELEPHONE NUMBER: �; � 31 1� D R 9 Town of Barnstable CONTACT PERSON: \,� P.O. Box 534 EMERGENCY CONTACT LEPHONE NUfMBER: -- r-)Ts 9 Hyannis, MA 02601 TYPEOFBUSINESS: 1 \10S Does your firm store a of the toxic or hazardous materials listed below, either for sale or for you own use? YES NO This form must be returned to the Board of Health regardless of a yes or no answer. Use the enclosed envelope for your convenience. If you answered YES above, please indicate if the materials are stored at a site other than your mailing address: ADDRESS: TELEPHONE: LIST OF TOXIC AND HAZARDOUS MATERIALS The Board of Health has determined that the following products exhibit toxic or hazardous character- istics and must be registered regardless of volume. Please estimate the quantity beside the product that you store. NOTE: LIST IN TOTAL LIQUID VOLUME OR POUNDS. Quantity Quantity Antifreeze(for gasoline or coolant systems) Drain cleaners NEW USED Cesspool cleaners pp ,, Automatic transmission fluid Disinfectants bk(P4_GIC'`& Engine and.radiator flushes—., _ __ _. _ Road Salt Halite). Hydraulic fluid (including brake fluid) Refrigerants Motor oils Pesticides NEW USED (insecticides, herbicides, rodenticides) Gasoline, Jet Fuel Photochemicals (Fixers) Diesel fuel, kerosene, #2 heating oil NEW USED Other petroleum products: grease, Photochemicals (Developer) lubricants, gear oil NEW USED Degreasers for engines and metal Printing ink Degreasers for driveways & garages Wood preservatives (creosote) Battery acid (electrolyte) Swimming pool chlorine Rustproofers Lye or caustic soda Car wash detergents Jewelry cleaners Car waxes and polishes Leather dyes Asphalt & roofing tar Fertilizers Paints, varnishes, stains, dyes PCB's Lacquer thinners Other chlorinated hydrocarbons, NEW USED (inc. carbon tetrachloride) Paint & varnish removers, deglossers Any other products with "poison" labels Paint brush cleaners (including chloroform, formaldehyde, Floor & furniture strippers hydrochloric acid, other acids) Metal polishes Laundry soil & stain removers Other products not listed which you feel (including bleach) may be toxic or hazardous (please list): Spot removers & cleaning fluids (dry cleaners) LI Other cleaning solvents Bug and tar removers WHITE COPY-HEALTH DEPARTMENT/CANARY COPY-BUSINESS I COMMONWEALTH OF MASSACHUSETTS �L EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS Cv DEPARTMENT OF ENVIRONMENTAL PROTECTION TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 1046 Main St. Osterville, MA _ Owner's Name: Village West Condo Assoc. Owner's Address: p O Box 550 ngtPruji MA Date of Inspection: Name of Inspector: (please print) W i 1 1 i am E_ • Ro i nson Sr. Company Name: William E. Robinson Septic Service Mailing Address: P O Box 1 089 Centerville, - MA Telephone Number: (5 0 8 ) 7 7 5-8 7 7 6 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems.I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system:-' Passes 1 Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails i Inspector's Signature:' e - _ _� Date: __ ; _ The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Hea&,or DEP)within 30 days of completing this inspection.If the system is a shared system or has a design flow of 10,600 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving authority. Notes and Comments . ° ""This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. Title 5 Inspection Form 6/15/2000 page 1 Page 2 of l l OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 1046 Main St. Osterville Owner: Village West Date of Inspection: Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. Syst Passes: I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. . Comments: B. ystem Conditionally Passes: One or more system components as described in the"Conditional Pass"section need to be replaced or repair d.The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. Answe yes,no or not determined(Y,N,ND)in the for the following statements.If"not determined"please explain. e septic tank is metal and over 20'years old*or the septic tank(whether metal or not)is structurally unsoun exhibits substantial infiltration or exfiltration or tank failure is imminent.System will pass inspection if the existing is replaced with a complying septic tank as approved by the Board of Health. •A me I septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicat g that the tank is less than 20 years old is available. ND a plain: Observation of sewage backup or break out or high static water level in the distribution box due to broken or obs cted pipe(s)or due to a broken,settled or uneven distribution box.System will pass inspection if(with appr val of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND a lain: The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will pas pection if(with approval of the Board of Health): i broken pipe(s)are replaced obstruction is removed ND explain: Page 3 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 1046 Main St. Osterville Owner: V' Date of Inspection: 1-2 — a C. Further Evaluation is Required by the Board of Health: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is fail g to protect public health,safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the ystem is not functioning in a manner which will protect public health,safety and the environment: Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh. 2. S stem will fail unless the Board of Health(and Public Water Supplier,if any)determines that the syste is functioning in a manner that protects the public health,safety and environment: The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a rface water supply or tributary to a surface water supply. The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more front a rivate water supply well**. Method used to determine distance *This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform cteria and volatile organic compounds indicates that the well is free from pollution from that facility and t e presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other f ilure criteria are triggered.A copy of the analysis must be attached to this form. 3. ther: , 3 Page 4 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 1 0 4 6 Main St. Osterville Owner: ge West Date of Inspection: D. System Failure Criteria applicable to all systems:. You ust indicate"yes"or"no"to each of the following for all inspections: Yes o Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool _ Liquid depth in cesspool is less than 6"below invert or available volume is less than '/z day flow _ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped Any portion of the SAS,cesspool or privy is below high ground water elevation. Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. _ Any portion of a cesspool or privy is within a Zone I of a public well. _ Any portion of a cesspool or privy is within 50 feet of a private water supply well. _ Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form.] ( s/No)The system fails.I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails.The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Larg Systems: To be con idered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd• You must indicate either"yes"or"no"to each of the following: (The foil wing criteria apply to large systems in addition to the criteria above) yes n the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply _ the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped .. Zone II of a public water supply well If you ave answered"yes"to any question in Scctwo E the system is considered a significant threat,or answered "yes"i Section D above the large system hu failed.The owner or operator of any large system considered a signific nt threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304.The system owner should contact the appropriate regional office of the Department. 4 Page 6 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 1046 Main St Osterville Owner: Villa e West Date of Inspection: A FLOW CONDITIONS RESIDENTIAL Number of bedroom (design): Number of bedrooms(actual): DESIGN flow base on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): Number of current es1,dents: Does residence h e a garbage grinder(yes or no):'_ t: Is laundry on a s parate sewage system(yes or no):_ [if yes separate inspection required], Laundry syste inspected(yes or no):_ r Seasonal use: yes or no): Water meter eadings,if available(last 2 years usage(gpd)): 2000 246,000 gal Sump pum (yes or no):_ ,0 0 0 ga 1 Last date of occupancy: COMMERCIAL/INDUSTRIAL Type of establishment: S6-Id , S Design flow(based on 310 C 15.203): gpd Basis of design flow(seats/persons/sgfr,etc.): Grease trap present(yes or no): Industrial waste holding tank present(yes or no): � Non-sanitary waste discharged to the Title 5 system(yes or no):,,&L0 Water meter readings,if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION , Pumping Records i Source of information: Was system pumped as part of the'inspection(yes or no): � If yes,volume pumped: gallons--How was quantity pumped determined? , Reason for pumping: TYP�OF SYSTEM _✓✓Septic tank,distribution box,soil absorption system _Single cesspool _Overflow cesspool _ —Privy _Shared system(yes or no)(if yes,attach previous inspection records, if any) _Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner) Tight tank _Attach a copy of the DEP approval Other(describe): Approximate age of all components, ate in tailed(if known)and source of information: c 66 Were sewage odors detected when arriving at the site.(yes or no): � 6 a` , Page 5 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 1046 Main St. Owner: IN I ale West Date of Inspection: j -D!/ Check if the following have been done You must indicate"yes"or"no"as to each of the following: Yes o Pumping information was provided by the owner,occupant,or Board of Health T�Were any of the system components pumped out in the previous two weeks? the system received normal flows in the previous two week period? Have large volumes of water been introduced to the system recently or as part of this inspection? L Were as built plans of the system obtained and examined?(If they were not available note as N/A) l/ Was the facility or dwelling inspected for signs of sewage back up? 1/ Was the site inspected for signs of break out? Were all system components,excluding the SAS,located on site? t/ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition of the_baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum? Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems The size and location of the Soil Absorption System(SAS)on the site has been determined based on: Yes no Existing information.For example,a plan at the Board of Health. Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 CMR 15.302(3)(b)] 5 Page 7ofII ' OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 1046 Main St_, Osterville Owner: Ville West T Date of Inspection: B [I DING SEWER(locate on site plan) Dep below grade: Mater als of construction:_cast iron _40 PVC_other(explain): Dis Ice from private water supply well or suction line: Co ents(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK: (locate on site plan) Depth below grade: _ Material of construction: ✓concrete metal fiberglass_polyethylene —other(explain) If tank is metal list age:_ Is age confirmed by a'Certificate of Compliance(yes or no):_(attach a copy of certificate) ► , Dimensions: Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle: L Scum thickness: , Distance from top of scum to top of outlet tee or baffle: , Distance from bottom of scum to bottom of outlet tee or baffle: How were dimensions determined: Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of.leakage,etc.): GeaLnS >d �,2a GREASE TRAP:_(locate on site plan) Depth below grade: Material of construction:_concrete +'metal_fiberglass polyethylene_other (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): Page 8 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 1046 Main St. Osterville Owner: Village West Date of Inspection: --�2 •-is TIG T or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan) Depth elow grade: Materia of construction: concrete metal fiberglass polyethylene other(explain): Dimensi ns: Capacity. gallons Design F w: gallons/day Alarm pr sent(yes or no): Alarm le el: Alarm in working order(yes or no): Date o ast pumping: Comm is(condition of alarm and float switches,etc.): DISTRIBUTION BOX: of P resent must be o ened)(locate on site plan) P Depth of liquid level above outlet invert: Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of. leakage into or out of box,etc.): PUM CHAMBER: (locate on site plan) Pumps in working order(yes or no): Alarm in working order(yes or no): Co ents(note condition of pump chamber,condition of pumps and appurtenances,etc.): 8 r - Page 10 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 1046 Main St. . Osterville Owner: village West R. w Date of Inspection: SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks.Locate all,wells within 100 feet.Locate where public water supply enters the building. 16 10 Page 9 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 1046 Main S t_ Osterville Owner: Vi 1 1 age West Date of Inspection: �-2t7- o I SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,excavation not required) If SAS not located explain why: Ty�leaching pits,number: leaching chambers,number: leaching galleries,number: leaching trenches,number,length: leaching fields,number,dimensions: overflow cesspool,number: innovative/alternative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation, etc.): L L✓ CE , POOLS: (cesspool must be pumped as part of inspection)(locate on site plan) Numbe and configuration: Depth—top of liquid to inlet invert: Depth o solids layer: Depth of cum layer: Dimensio s of cesspool: Materials f construction: Indicatio of groundwater inflow(yes or no): Commen (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): PRIVY. (locate on site plan) Mater Is of construction: Dimens ons: Depth o solids: Comme s(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): 9 f Page 11 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 1046 Main St Osterville Owner: Village West Date of Inspection: i-2 c7—D I SITE EXAM Slope Surface water Check cellar - Shallow wells Estimated depth to ground water Q-0. feet Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record-If checked,date of design plan reviewed: bserved site(abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health-explain: Checked with local excavators,installers-(attach documentation) Accessed USGS database-explain: You must describe ow you established the high ground water elev3jl ll O a e. - .5 � d1'eS . . Y 11 .. .. 1 P�o4THE Ta�y �_ TOWN OF BARNSTABLE k OFFICE OF = Basa9TSBL i BOARD OF HEALTH vo i639' \0m 0 MA'S 367 MAIN STREET HYANNIS, MASS.02601 November 19, 1996 To: All Owners of Hair Salons Connected To Onsite Sewage Disposal System Located In The Town Of Barnstable On November.5, 1996,the Board of Health voted to issue the following policy relating to hair salons:t. 1) Every owner of any new hair salon and any existing hair salon which is seeking approval to install additional seats in the hair salon which is,connected to an onsite sewage disposal system, shall submit plans for a holding tank prepared by a professional engineer or registered sanitarian. The holding tank shall be designed to collect industrial wastes, not sewage wastes. The plans shall be designed in accordance with 310 CMR 15.260 and shall be submitted to the Department of Environmental Protection and the Board of Health prior to opening for business or prior to installing additional seats. ' 2) Every owner of a new hair salon and any existing hair salon which is seeking 'approval to install additional seats in the hair salon and which is connected to an onsite sewage disposal system, shall install a holding tank,in accordance with the approved plans, prior to opening for business(or in the case of increased seating,prior to installing any additional seats). The holding tank shall be installed by a disposal works installer who is licensed by the Town of Barnstable. (3) All hair salons in existence prior to November 20, 199E will be contacted by the Board of Health regarding a holding tank policy after the completion of the University of Massachusetts Study and after receiving communication(s)from the MA Department of Environmental Protection. If you should have any questions,please contact the Public Health Division Office at 790-6265., *Definition of"new" -'A proposed hair salon which will open for business after November 20, 1996. PER ORDER OF THE BOARD OF HEALTH Susan G."Ifask, .S.,thErman x R. Grad ; S. li--M hy,M.D. Board 0`Health �- Town of Barnstable oFTHE ro TOWN OF BARNSTABLE OFFICE OF = 3ARX9TMM 'BOARD OF HEALTH y raaa � 0o 039' \gym 367 MAIN STREET CEO Mix k" HYANNIS, MASS.02601 November 19, 1996 To: All Owners of Hair Salons Connected To Onsite Sewage Disposal System Located In The Town Of Barnstable On November.5, 1996,the Board of Health voted to issue the following policy relating to hair salons: 1) Every owner of any new hair salon and any existing hair salon which is seeking approval to install additional seats in the hair salon which is connected to an onsite sewage disposal system, shall submit plans for a holding tank prepared by a professional engineer or registered sanitarian. The holding tank shall be designed to collect industrial wastes,not sewage wastes. The plans shall be designed in accordance with 310 CMR 15.260 and shall be submitted to the Department of Environmental Protection and the,Board of Health prior to opening for business or prior to installing additional seats. 2) Every owner of a new hair salon and any existing hair salon which is seeking approval to install additional seats in the hair salon and which is connected to an onsite sewage disposal system,shall install a holding tank,in accordance with the approved plans, prior to opening for business(or in the case of increased seating,prior to installing any additional seats). The holding tank shall be installed by a disposal works installer who is licensed by the Town of Barnstable. (3) All hair salons in existence prior to November 20, 1996 will be contacted by the Board of Health regarding a holding tank policy after the completion of the University of Massachusetts Study and after receiving communication(s)from the MA Department of Environmental Protection: If you should have any questions,please contact the Public Health Division Office at 790-6265. *Definition of"new" -A proposed hair salon which will open for business after November 20, 1996.. P R ORDER OF THE BOARD OF HEALTH Susan G. k, S., hairman • R Grad , S• Diu ,N .. h',M . hy,M.D. Board o`4dtii �- Town of Barnstable c salons TOWN OF BARNSTABLE COMPLIANCE: CLASS: 1.Marine,Gas Stations,Repair satisfactory 2.Printers BOARD OF HEALTH 3.Auto Body Shops y�� unsatisfactory- 4.Manufacturers COMPANY, a MW AA2,,9- (see Orders") 5.Retail Stores qyfi,I/z.Q� 6.Fuel Suppliers ADDRESS / 1-3d� Class: 7 7.Miscellanepus ��i •s:L� QUANTITIES AND STORAGE (IN=indoors;OUT=outdoors) MAJOR MATERIALS Case lots Drums Above Tanks Underground ks IN OUT I IN I OUT IN OUT #&gallons Age Test Fuels: Gasoli ,Jet Fuel(A) Diesel,�erosene,#2(B) Heavy 'Is: waste otor oil(C) new m or oil(C) r transmi sion/hydraulic Syntheti Organics: degreas rs Y Miscellaneous: r DISPOSAU/RECLAMATION REMARKS: 1.Sanitary Sewage 2.Water Supply - O Town Sewer A(Public ,Von-site OPrivate 3.Indoor Floor Drains YES NO O Holding tank:MDC_ O Catch basin/Dry well P > O On-site system 4.-Outdoor Surface drains:YES NO O Holding tank:MDC O Catch basin/Dry well O On-site system 5.Waste Transporter Na me of Destination Waste Product , YES Nu 1• r ilJH 2. Person((1/Interviewe Inspector Date TOWN 1V OF BARNS TABLE COMPLJANCE: CLASS: 1.Marine,Gas Stations,Repair satisfactory 2•Printers BOARD OF HEALTH 3.Auto Body Shops unsatisfactory- 4.Manufacturers COMPANY'2�u�1, C� /r��l�Z7t"1tS��. (see"Orders ) 5.Retail Stores 6.Fuel Suppliers ADDRESS Class: 7.Miscellanepus QUANTITIES AND STORAGE (IN=indoors;OUT=outdoors) MAJOR MATERIALS Case lots Drums IN OUT IN OUT IN OUT #&gallons 177 Test Fuels: Gasoli ,Jet Fuel(A) Diesel, erosene,#2(B) Heavy ls: waste Iotor oil(C) new m r oil(C) transmi sion/hydraulic Syntheti Organics: degreas rs Miscellaneous: 77 i DISPOSALIRECLAMATION REMARKS: 1.Sanitary Sewage 2.Water Supply 0 Town Sewer JYPublic 'Von-site OPrivate 3.Indoor Floor Drains YES NO Y 0 Holding tank:MDC_ - h O Catch basin/Dry well 7 - O On-site system 4.Outdoor Surface drains:YES NO O Holding tank:MDC a •t O Catch basin/Dry well 0 On-site system 5.Waste Transporter DestinationName of Hauler � YES NO 2: Person( )Interviewe Inspector Date No....,C--7. .'76--C, F ._............... HE COMMONWEALTH OF MASSACHUSETTS BOAS OF HEAL �� ,0 104 Applira#ion for Disposal Works Tonstr7�anLIndividual n rrmi# Application is hereby de for a Permit to Construct ( or Repair ( Sewage Disposal Sys . ......... __. ..... ....- - i� ./.� .,�-.�......----•--------•-••---•--------•............... •Lola` ,A��-- or o. Cy 'J/ftt �/ Lot N ._........ ............. ---?;;e Z � ...•..... ........e..e....�.�s---------' ........................... ..... .....'--......_.._..... ._ ..---Ir Instr Address UType of Building Size Lot............................Sq. feet Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) Otherfixtures --------•--------------- ------•-•-------------.......--•-•-•'-•----------------------- -------------------•--•--'•-••......---•••-•---- ... W Design Flow............................................gallons per person per day. Total daily flow...........................................gallons. WSeptic Tank—Liquid capacity............gallons Length................ Width................ Diameter.---.-------_- Depth--...--..--..... x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area--------------------sq. ft. Seepage Pit No--------------------- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( )- Dosing tank ( ) Percolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................ 44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water-_--------------------- 9 ...............................:......................................................................................................... -------------- --- 0 Description of Soil....................................................................................................................................--•--------•...... ................ -------------------------------------------------- t-� - -----------------------------------'•'---------••-•-------•-------------------•----------•------------------------- UW •---•-••...'-----------------------•--••--------•--------------------•--•••----------•------'-•--.......----. - // Nature o epairs or Iterations—A w r wh applicable.-...... -+ -dD12 -------------- Agreemen : The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of i!'I TIE 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has'bee s of hth. Signed-•-• . :. •'-• --'- ............................ Date Application Approved B PP PP Y .",^� ----------------------•------------ --------------------------------------- Date Application Disapproved for the following reasons-...............................................................................................................-- ..........................................................................................................---•----•-•--•--•••-'••--•-------.........---•-•------•------•-•-----'---------------••-------- Date Permit No........ - �'�Z2. --•---......-- -• --------•------• Issued....................................................... Date e. � THE COMMONWEALTH OF MASSACHUSETTS Appliration for Disposal Works Tonstrurtion Funtit /�~aSy n Individual Sewage Disposal � ibn d;;Pis or Lot No. Installer Address 14 Type of Building Size feet Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) Other—Type of Building ............................ No. of persons............................ 6bowcca ( ) -- Cafeteria ( ) 'w Other fixtures ------------'---------'--'''-------------''--------------------------- Deeign Flow............................................gallons per person per day. Total daily flow............................................ . Septic Tank—Liquid ............gallons Length................ Width................ Diameter---------------- Depth................ Disposal Trench--No .................... Width.................... Total Length.................... Total leaching area--------------------sq. {t. Seepage Pit No.----.---. Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) '- Percolation Test Results Performed bv........................................... .............................. Date....................................... � � Test Pit No. l-'---'--miuutcoyerincb Depth of Test Pit.----_--- Depth tn ground water........................ 44 Test Pb No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water---_'--.--. 0 ---_''-_---.-_--..----'----___-___---'--'-'----_-'----------------.-__-'---. Description of Soil........................................................................................................................................................................ / U _-_--'----.--'-_------__'_--------'-----'------.---_--_-------- ----'-'----------- ---_----_-'' Nature o -0,__V'V..... yelxl.. ........=�......................................................................... --------- � T� u��y � ��l �� �o����c �d�6�lS�u� D�o� S��� � u�o�a�e �� | � . - ^ ' �� � � the provisions ofZ[TlZ 5 of the State Code The undersigned further agrees not to place the system in operation until u Certificate of Compliance S' � �'-.��� '���'�'c����. ~�� , .~_--"--',-- '-'�e'`�---'- -------------------------- DateApplicationApproved "y-'----- --°��'��-~�~'^ ---'----------'--- ---------_--'--'--- � ° ~ ^ om=Application Disapproved � for the following reasons:--- .......................................................................................................... - � ____________________________________________________________________________________ Date �� - Permit 2�o-'--��-���-_�'�'��.C.2----------------- IueoedL....................................................... � Date THE ooMmomvvsALTH OF MASsAo*ossrrs � BO R ......OF.....Vj. ....................... � Trrtifiratr of Tompliaurr � n( stem co structO or � uy.......... --------------- application . _ .....-Y..~ dated-------------------------- ..................... � THE ISSUANCE SYSTEM WILL FUIOCTION SATISFACTORY. 0ATIL'----- -_______________ _ � | � THE COMMONWEALTH OF wAssmz*ussrrs !---OF-.» ---- __ ----------- i A y 01 - Rzo s I� Pik l U La-T' Lows UIS J` 1 Z000 10 0 i � n vcvs � APP 8 , MAP 118 ?ct_ 15 al9oeie> 70IJE � r a rn �� Q jFo v-m r=r- t,)I L3:>i 06, A , / lG TAy'L• 4 43 (L.ow62L) o 'Z2 Pir .` 4Z L)4 fr6 54 r IB p+Sr / uwrT Q. 1[o q UNIT 1 I ` h 1 a ' . . � � l� 1 (�pPt-iz} '� 211^ i �� ct.r• - 31 $Utt�i Q t9 UNIT 3 �; G_ 3� UNIT 1 {Lvw m-) ' 1 Cvrpa c G h �`"suMr`s1� H.r? ° y U 1217 b UQMs t-3 STor�S S`1S2 SF UO[TS d-11 cF1cC Cc�(5SF ��/ = �'1 SZ�c 5%cx� -4- _G&S �C�`>�c� = 1�9 �•P'h ; nC- �QL 1g9 X I SD�v' M19, a-`' U`.� Ivv GAG. 7AIJrL Frr - Z- (coo G,c- -TOTAL �sl&W l v`�c� Trn-A L .r G`u , j Y I t r,u 2 nn n� arz Ls� i E— xFvmT -- d bIST pox I �� 1 o' rlc Mom. t Al I ANC FI-2o 4-2o A&AaoLta ° w 2'0F b(a;i H _ S ✓ v p M n r^ 69 Z v p• FaAAAG !_oVls�zS -rO �AAUTie II ' 1p (� � I �/19(`�"E12. fZ �`�ls I►�C. ((-3 0-g7 E><l STf t� SCPft C Pc.aZ"TEL`> �1.- 35 ___ r2 S��LtSTC-�•L�`� lA� 5�►7�,/�`yvtLS Flo WAT p�3�afx ' e� ci ROGER G `r' RICHARDA. PAULA. MICHNIEWICZ r ^ r 0AXTr~Fi �' y N Cl L 420 a ,y